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03/25/2010 THU 13: 32 FAX 2094683433 SJC EHD 12002005 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M Arc V-� A O awa" <br /> —� <br /> OWNER/OPERATOR V l LL��� ��i CHECK If BILLING ADDRESS <br /> FACILITY NAME \/I L L A G G <br /> SITE ADDRESS �(I G. w <br /> 6,� '4 City <br /> Stroot Number Direction Stroet Namo Cil Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E77 APN# LAND USE APPLICATION# <br /> Qo�) <br /> PHONE#2 ExT. BIDS DISTRICTLOCATION CODE <br /> ( , <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr7��2� ( 1 ^�,1 L�� _ ���1 <br /> �t..[[�� I—}Yt � CHECK if BILLING ADDRESS® <br /> BUSINESS NAME � \ �\ �r^ PNONE�# � � �9ExT. <br /> HOME of MAILING ADDRESS �V �J FAX# l/O <br /> CITY C�� S STATE (::T� ZIP Q5 � <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.HLiAL•I'ii 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 <br /> FEDI RAI,la^ . <br /> APPLICANT'S SIGNATURE: WL��L�' l ''►�� DATE,: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O•rittemAUTuoRIzrDAcr.NT,k �G� r <br /> /f APPL1CANl'is not the BILL/NG PARTI 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTALL,HEALA'ii DEPARTMENT as soon as it is available and at the saine time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COIAMENTS: <br /> APR - 6 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY EMPLOYEE#: ` DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E. f1 <br /> Fee Amount: Amount Paid Payment Date � �5 <br /> Payment Type Invoice# Check# � Re eived y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />