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SAN JOAQI --OUNTY ENVIRONMENTAL HEALT ?PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME V J!, <br /> �SA tkn c-Ir <br /> SITE ADDRESS �� I,ti <br /> Street Number I Die tion Stred Name city Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> treat Number Street Nem <br /> CITY STATE W ti ZIP <br /> PHONE#1 EXT. APN flLAND USE APPLICATION# <br /> PHONE#T EXT. BOS DISTRICTLOCATIOLOCATION 7 <br /> ( ) 4 � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> MCLCHECK If BILLING ADDRESS <br /> BUSINESS NAME W PHONE EXT. <br /> • e�- �C �t��.a� tf ups +.��t. . -f��' �i�-- t��,•3 c� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ;' _ STATE �/� ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: �5 j, 1.E�� DATE: 5-1l lam`j <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 15 4%4Zt(((LC(' (amJ ITL.Cx V <br /> If9PPLICANT is not the BILL/NG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 REQUESTED: 5�� �2tt f PAYNf IvEn <br /> EIS <br /> COMMENTS: ('60-V, CJ�+�« at ��Q Ql(Cat"'e(t i MAY 2 U 2009 <br /> y, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: O 1 ✓�[ EMPLOYEE M O 3.Z DATE: �d <br /> ASSIGNED TO: �+ EMPLOYEE M ZZ� DATE: S 2 �/U <br /> Date Service Completed (if already completed): SERVICE CODE:��� P)E: 3CG,r <br /> Ift <br /> Fee Amount: _ 3 js.`r-L) Amount Paid 3 s Payment Date <br /> Payment Type ✓ Invoice# Check# b Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />