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SAN JOAQUPT COUNTY ENVIRONMENTAL HEAL T-r DEPARTMENT -t-C)(:) <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br /> <br />SITE ADDRE..5 ...._e <br />3 --.b, / Street Number Direction <br />/1•40/e---C-7/4Ai /(74.ze <br />Name Street <br />4,57-er--e--/V <br />City <br />.FS--- (7/0 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />P14144- e-V DN Pc),13 PHONE # ,g61) zoti-.2. 3-(-467--. <br />Err. <br />HOME or MAILING ADDRESS <br />V-370 /t-dlik („an C--- I ge-A <br />FAX # <br />( ) <br />CITY i_- OPI sTATEc_ii_ ZIP 9,....0 <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, STAT FEDE L laws. <br />APPLICANT'S SIGNA <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWN OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />rovided to me or my representative. _ <br />TYPE OF SERVICE REQUESTED: /W)L.-- ne4A/ 7/1-C--C6-- PAYMENT HECEIVCD <br />COMMENTS: voz JUN i 2 2009 <br />sINJvc1ABoopuEr,,,it,ADNAECIRtiv°TUAENLNTYT <br />ACCEPTED BY: <br />--c7/1n <br />EMPLOYEE #: 7..;).0 DATE:, 6,7147 <br />ASSIGNED TO: AV-A 44 EMPLOYEE #: 4.2,13 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: _.- 2. 2...---- <br />Fee Amount: c's Amount Paid (D . 'C'i) <br />Payment Date (p_LD 1' <br />Payment Type Invoice # -Check # [f 0 (c)--1 r Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003