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SAN JOAQU CSERVICE REQUEST ENVIRONMENTAL HEAL'�EPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 134C-3 Stcpo SS0t,o10 <br /> OWNER/OPERATOR <br /> S�IA CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I e$F — ' 7 l e —ACJ C+ �53� / <br /> Street Number Direction •�/`-'�1 `Y I""� Street Name T� <br /> HOME or MAILING ADDRESS (If Different from Site Address) ci zl code <br /> r C q �.� <br /> CITY _� <br /> Street Number Street Name <br /> ( 9/-7 <br /> e5STATE zip 7�> <br /> PHONE 91 Exr. APN# <br /> q'o�) ^.r2 . r�- LAND USE APPLICATION# <br /> PHONE#2 Exr. <br /> (ZuBOS DISTRICT LOCATION CODE <br /> q ) O�IL til `�0�2 S <br /> ----------------- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY ( ) <br /> STATE ZIP <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: If ,'-,__ s N"L-. '\' >— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 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: S'1- Coe4) S'LC L7-.14_--7 D PAY D <br /> COMMENTS: <br /> AUG 6 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L f U E 1 Y2-r"C EMPLOYEE#: 2, DATE: er <br /> ASSIGNED TO: / � <br /> r L/L 4 EMPLOYEE#: SCrc(Z DATE: W&( tOe' <br /> Date Service Completed (' already completed): SERVICE CODE: d�/ PIE: <br /> Fee Amount: 1P 1C, S ChJ Amount Paid l�S Payment Date D <br /> Payment Type <br /> CA5R Invoice# Check# o <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />