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SAN JOAQUIN 'JNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .:23 `f5 '"oGo/3 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> e— S <br /> SITE ADDRESS E,3 Sl=q mo,A`b,C 9.S Z\q <br /> Street Number I Direction Street Name city Zip Code <br /> HOME of MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION If <br /> ( ) © 2-foo - 58" <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME — PHONE If EXT' <br /> ` — 1.10 <br /> - <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE G At ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE, and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENt/M •N!!Lh <br /> IJAPPLICANT iS not the BILLING PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: O0L <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> JUN - 3 2010 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENITAL <br /> HEALTH 0 P <br /> ACCEPTED BY: 0 U IUE n Y;-9AEMPLOYEE#: O 3� DATE: (0 <br /> ASSIGNED TO: �E/� L/� EMPLOYEE#: 6�r3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SL 2� PI E3 <br /> Fee Amount: !�� GV Amount Paid _ Payment Date 3 <br /> Payment Type `/ Invoice# Check# t j 3 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />