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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHLEPAictDint.r <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNERI OPERATOR t C0 CHECK ifBILLINGADDRES <br /> FACILITY NAME �u I <br /> �o �L^ `'kLD �s- C <br /> SITE ADDRESS �ao'S't�-e- ' Ci ����' \Zi Code <br /> Street Number Direction Street Name <br /> HOME Or MAILING ADDRESS Iff niffnrontt fr�ty^�Sita AddrrPSSS,I 3 7 <br /> `'M" ��,[reel Number Street Name <br /> CITY STATE ZIP <br /> Exi• APN# LAND USE APPLICATION# <br /> PHONE#1 C)Ze^D C/ <br /> L <br /> (� ) ' 1 ) I 7LOCATION CODE <br /> PHONE#2 E'IT• BOS DISTRICT _ <br /> (:28) 6o i n a 51f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS 0 <br /> tt/LlS' �'•vtc EXT. <br /> BUSINESS NAME PHONE# <br /> HOME or MAILING ADDRESS FAX# <br /> ) <br /> CITY 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: �o.nn c�� � -4� DATE: 3I I T <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICANT 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 envirorunentaUsite 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: e.C?tJ S Lt-/-7->+-1-Z B rJ n-/ECA J hiq <br /> COMMENTS: C'EI VED <br /> MAR 13 2009 <br /> �VIF?ON COUNTY <br /> HEALTH DEPMEMAL <br /> ACCEPTED BY: DLf� I �O EMPLOYEE#: D3Z DATE: 3 I3 0 <br /> ASSIGNED TO: gA ",.•{tZ EMPLOYEE#: Og DATE: 3 13 Q <br /> Date Service Completed (if already completed): SERVICECODE: PtE: 1(o62— <br /> Fee Amount: �O�F,vZ Amount Paid B iv.— _ Payment Date 3 / 3 D <br /> PLO <br /> Payment Type Invoice# Check# j (Q Received By: <br /> EHD 48-02-025 �;SF€ t. tll�iri'Rtld) s <br /> REVISED 11/17/2003 <br />