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SAN JOAQL OUNTY ENVIRONMENTAL HEALTH kARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,+S STA-i 11)N CAQ15V <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADORE55GIGL ")ANbHeQ /NVFS7-AfC-"7-1t LLL Er <br /> FACLTYNAME <br /> W/' ,C COVATgY STA- I I D A <br /> SITEADDRESS /I / 1:NumbeLA <br /> " L O <br /> St. recti <br /> Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 E><r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n _ �r <br /> KEL1�L6QE'I72oLEu9 �t� C'kUlCtrS , fN( . CHECK ItBILLING ADDRESS <br /> BUSINESS NAME PHONE# EZT. <br /> 2oq gUr- BsSb <br /> HOME or MAILING ADDRESS '52- 1 g R 4 N I )A/�r /,eD J&1 r�. (An Ae) U rl <br /> CITY ®1�K'7,A-LC STATE �1Gr/A 1 ZIP g5�36 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applic bn and that th irk 10 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE nd FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: o l I 0 1 I <br /> PROPERTY/BUSINESS OWNER a OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT64 <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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 4zC1 1r qT <br /> COMMENTS: C-O /lSTA-KT / C v R V P hi f—Wb 61— RECEIVED <br /> am✓T JAN 0 8 2009 <br /> CALL 'rA-n1nE-670 ( 4.00 �Lo�—?Iq g cc Pe <br /> <} Pped✓t4L ROC EME R�LATTA <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: CAEMPLOYEE#: /lY DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type t/ Invoice# Check# Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />