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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busine s or Property FACILITY ID# SERVICE REQUEST# <br /> r � �P� <br /> OWNER/OPERATOR <br /> a SePN /)A/7 / ff/.(C6/ ,. / CHECK If BILLING ADDRESS <br /> FACILITY N`A /"LCL �rJJC.l7`� <br /> VV,9 DRYS p �j <br /> 1T s LDR�SS PSve city <br /> HOME `'l'V Street Number Olrection Street Name I ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> S N"\ Streel Number Street Name <br /> �/�- STATE ZIP <br /> PHONE#1 EXT* APN# LAND USE APPLICATION <br /> (2� 2.S C �� � ) 1 6 62-�L)0+ <br /> PHONE#2 EXT. BOS DISTRICT,/ LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ ' /n, i <br /> CHECK If BILLING ADDRESS <br /> VA BUSINEs,SeN ME ^n PANE# Z[J EXT. <br /> ll/ / / 1 <br /> HOME or MAILING ADDRESS , FAX# <br /> CITY O ,i/ J�E 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 /> 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,ST ERAL IawS. n <br /> APPLICANT'S SIGNATURE: _ L DATE: '--G,r� <br /> _ I <br /> PROPERTY/BUSINESS OWNER Iy OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It IS available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: i Z— -F) PAYMENT ENT <br /> COMMENTS: RECEIVED <br /> Ne-W UVUt�l4..� <br /> JAN 2 2 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: J uL1iO UZ. <br /> 1. <br /> Fee Amount: �� Z<r-� Amount Paid S � _ Payment Date I , <br /> Payment Type GIC— Invoice# Check# t I L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />