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JAN-16-2009 15.56 Ser-.,ice Station Systems 408 938 8888 P.05 <br /> SAN JOAQt -OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9. k r K— <br /> OWNER/OPERATOR <br /> CHECK It BILLINQ ADDRESS <br /> FACILITY(NAME <br /> SITE ADDRESS —St <br /> net Number D rection strowl N <br /> HOME Or MAILING ADDRESS (N Different from Site Address) <br /> Street Number t Namr <br /> CITY STATE <br /> ZIP <br /> PHONE 01 E" APN it LAND USE APPLICATION 8 <br /> (?L)5 ) a <br /> PRONE#2 EXT. <br /> SOS DISTRICT 11 LOCATION CODE 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REGt1ESY0R 1.4 <br /> 1917S CHECK if BILLING ADDRESS <br /> BUSINESS NAM,:5E►- PHONE# EXT. <br /> VSE 5 Fl-1F� S S' � r L . IMC �& - 211 <br /> How or MAIUNG ADDRESS FAx <br /> ci >M <br /> n _ <br /> p S�i STATE ZIP <br /> ~II � <br /> AUJJNG ACKNOWLESFMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVTRONMENTAi-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 1 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: J� _,-//=!�_ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 2 <br /> /fAPPLICANT is not the BILLING PARTY,Proof of authorization to sign is required rrrlr <br /> Al11H2RIZATION TV REI, &U INFORMA'JON, When applicable,1,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 RECUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE*: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Foe Amount: Amount Pald Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712= <br />