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PHONE # <br /> EXT. <br />FAX # <br />) <br />APPLICANT'S SIGNATU <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWN OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUP" nOUNTY ENVIRONMENTAL HEALT — 4)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />0 / <br />SERVICE REQUEST # <br />sec° L5716i <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ; <br />1 <br />/ L <br />e r-5- h9'") /4- PC d <br />do <br />SITE ADDRES(L3o%..." r-% <br />LZ (5—A( Direction <br />/4rejele-1-- g l'a bio <br />Street Name <br />_rb4A-tion <br />City Zip Code Street Number <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />City STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 0 CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />q0/7 75 <br />HOME orAVIAILING ADDRErS <br />x ? / Maa9iiiitg <br />CITY G4 ZwiAr/kia) <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, STA nd FEDERAL laws. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> 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 />PAYMENT TYPE OF SERVICE REQUESTED: 7-eV& _Sj.--;'4 /267-37ip 1)fiY /--1Z AnL RECEIVED <br />COMMENTS: <br />° (41(I7N.Q1 <br />JUL - 1 2009 <br />SAN JOAQUIN COUNT) <br />ENVIRONMENTAL H LTH DEPARTMENT <br />k -116a <br />-----7 _ <br />ACCEPTED BY: <br />• <br />EMPLOYEE #:3-c24,..-iy DATE: L. <br />ASSIGNED TO: r i , <br />V 1 f V ir" A Al <br />EMPLOYEE #: 314-7-4"6026 DATE: ......1--q <br />Date Service Completed (if already completed) SERVICE CODE: 5-Q 2 PIE: <br />Fee Amount: fk P---t 0 Amount Paid %;t o. 0 0 Payment Date 7b10, <br />Payment Type * 0 Invoice # Check # Lt ( .;._, I Received By: <br />STATE ZIP <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003