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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Q -S26C- Sgy31 <br /> OWNER/OPERATOR <br /> (_JJ` C),( CHECK If BILLING ADDRESS <br /> FACILITY NAME U O -2-1 PL- <br /> SITE ADDRESS <br /> 3 12 � c'a 11- -y t, CIL 4e)1 qs z o <br /> Street Number ire ticm 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 EXT. APN# LAND USE APPLICATION# <br /> (20Lf1 2(OC <br /> i C. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �� STATE co ZIP 1?5-Z((o <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 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: DATE: 2�/7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART),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: T fJ <br /> COMMENTS: ECE/WD <br /> FEB 2 6 2010 <br /> SAN JOAQUIN <br /> NFq�TM p L <br /> ACCEPTED BY: EMPLOYEE#: '5-7 (,� DATE: r <br /> ASSIGNED TO: ( EMPLOYEE#: 1 DATE: (2 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: v2 <br /> Fee Amount: 1,/s Amount Paid `J? q s _ Payment Date- - Z ZbJ U <br /> Payment Type ✓"� Invoice# Check# Received By: `V — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />