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t *I. <br />Type of Business or Property FACILITY ID # <br />Facility Name <br />Site Address <br />Streot Numbor Zip Coda <br />Stroot Numbor <br />BOS District Location Code <br />Zip <br />r <br />Date:Accepted By: <br />Date:Assigned to: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />Date Service Completed (if already completed): <br />^01^ <br />Invoice # <br />Type of Service Requested: <br />Comments: <br />State <br />Land Use Application # <br />Amount Pal^> <br />Check # <br />Check If Billing AddressE[ <br />Ext. <br />Employee#: L <br />Employee#: <br />Service Code: ^'^'3 <br />Payment DateFee Amount: <br />Payment <br />\%O33 . <br />San Joaquin County Environmental Health Department <br />_______service request_______(\ee^ ftZ <br />Owner I Operator 7? J- ! / i <br />Direction <br />Home or Mailing Address (if Different from site Address) <br />C"Y"Tu^(£><^K______ <br />PHONE #1 EXT- <br />^3 ^^33J- <br />Phone #2 ext. <br />( ) <br />By: <br />APN# <br />^^^5 0-3^0 <br />z II <br />/n6. <br />— f NJ LU c AA <3 J M wv <br />e, 6>A4at <br />SERVICE REQUEST# <br />I I <br />__^)OT3?// <br />Fax# <br />(__1 <br />state rA <br />__ _________________CONTRACTOR / SERVICE REQUESTOR <br />Requestor^Axj-A (CHAk\U. ( <br />Business Name-t-. L _ <br />_________C-HAia £>1 P-O U ? <br />Home or Mailing Address <br />~~Po Key 3^0_______________ <br />Cm3u^ lo^K_______________________________________STATER zr <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/ind Federal laws. t i <br />APPLICANT’S SIGNATURE: C3?- Date: 3/^/^/ <br />Property / Business Owner □ /GpeXxtor / Manager □ Other Authorized Agent <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the San Joaquin County Environmental Health Department as soon as it is available and at the same time it is provided to me or <br />my representative. ___________________________ ________ _________________ z________-x________V/b? <br />I 20^ <br />^JTl^ <br />?>ln /7-z <br />PfT 1^1 3>/n 3d <br />Received By: <br />V A!mm3u ^ast-=. <br />_______________Street Nama ^38 ( <br />Zip <br />T f Check if Billing Address^.