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SAN JOAQL 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 <br /> SITE ADDRESS <br /> Street Number Direction l/ Street Name cityZi 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 /> ( 2o�i) c182 - 099-7 f �3-��o a3 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) 514 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ �f � / � <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME '\„ P�� r PHONE# xT <br /> 3- Q <br /> S^OQ <br /> �-/ <br /> HOME or MAILING ADDRESS C 7 FAX# <br /> �o <br /> Box ss/o (Z'4?) 043- 3003 <br /> CITY STATE C/) <br /> ZIP C11526 <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 EDE laws. <br /> APPLICANT'S SIGNATURE: DATE: 5/1 U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: (�(S� 09-C-7YU F("7— <br /> RECEIVED <br /> COMMENTS: MAR 1 7 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ®ct Us:—::�t .e yL- EMPLOYEE#: 6371 DATE: -3 ./7(0 <br /> ASSIGNED TO: 0/i FA-LC E EMPLOYEE#: e,317 DATE: i--7A) <br /> Date Service Completed (if already Completed): SERVICE CODE: ( a Si I P 1 E: <br /> Fee Amount: r s- Amount Paid 3) S U Payment Date3,11.7 cj <br /> Payment Type Invoice# Check# `ass Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />