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SAN JOAQUTA'`BOUNTY ENVIRONMENTAL HEALT4OEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IID## SERVICE REQUEST# <br /> lam/ <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME A- <br /> $ITE ADDRESS 9_ r (JI5ZL <br /> Street Number Direction62n Stree a e Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ETT. APN# LAND USE APPLICATION# <br /> (cQ') qP-7 Q <br /> PHONE#2 Ems. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORI \ ,e �N <br /> '1 n CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHOOIE# E <br /> ' L — <br /> HOljp�O�AILING ADDRMQ,S <br /> FAx# <br /> CIN 4 it (� STATE `-1 ZIP I <br /> IL- <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: I _0= � DATE: Z-2,�-7-0(�1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a-- <br /> �fAPPLLCANT is not the BLLLLNGPARTY 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 to 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: ECOVE <br /> COMMENTS: FEB 2 9 2009 <br /> SAN EVIRONIN COUNTY <br /> ,, r� HEALTH DTAL <br /> EPAR EN7- <br /> ACCEPTED BY: EMPLOYEE#: 2VQO DATE: d <br /> ASSIGNED TO: EMPLOYEE#: e �' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ^L PIE: <br /> Fee Amount: e Amount Paid a Payment Date 'Z/ 21 D <br /> Payment Type t� Invoice# Check# y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />