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APPLICANT'S SIGNAT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />P A 0 00 <br />SERVICE REQUEST # <br />OWNER! OPERATOR <br />CHECK if <br />, .. <br />BILLING ADDRESS <br />FACILITY NAME <br />SITE AIRESS <br />76 /27 Street Number Direction I (2114Th 47/77: Street Name <br />.5,26/(74 0 2 <br />City Zip Code <br />g".37 90 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number . - Street Name • - <br />Crry STATE ZIP - <br />.. ... .. . <br />PHONE #1 Err. <br />( ) <br />APN # LAND USE APPLICATION # . <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Ated4,7,,z CHECK if BILLING ADDRESSEE-- <br />BUSINESS NAME PHONE # <br />3 <br />4.i <br />? V xi ZY92 <br />Ext. <br />S HomgrprIVIALING ADD RE 'S <br />0 616)/1' 7/ i <br />CITY <br /> <br />Fax # <br />( ) <br />1,1,,y4Zri ,? le <br />STATE( ZIP <br />BILLING ACKNOWLEDGEMENT: ACICNIOWLEDGEMENT: 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, ST d F DERAL laws. <br />DATE: — (/'7 <br />PROPERTY / BUSINESS OWNER!: OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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, geoteclutical 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: V6-is qt, /I- t (P3) Act/zelq- nPAympNT <br />COMMENTS: " t cEivED <br />- <br /> <br />JUN 1 <br /> <br />- . 2010 <br />SAN JOAQUIN <br />EA' -00NMECAIT3AitiNTY <br />ACCEPTED BY: lireeti,el EMPLOYEE #: zi 3 DATE: WO/ /// a <br />ASSIGNED TO: hszedit44j-t-k_ EMPLOYEE #: 6 2,/ 3 DATE: 67 /0/ ho <br />PIE: Date Service Completed (if already completed): SERVICE CODE: <5.3, a..., <br />Fee Amount: 5 ?so, crp, Amount Paid 2, s 0 _ Payment Date <br />L [ '1 1 t 0 <br />Payment Type L _------ Invoice # Check # .s z k g Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003