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,S <br />SAN JOA,, JIN COUNTY ENVIRONMENTAL MA i n DEPARTMENT <br />SERVICE REQUEST <br />Type Business o Property <br />FAULLITY 10 # <br />SERVICE REQUEST# �� <br />RECEIVED <br />AUG 2 7 2010 <br />� <br />OWNE / OPERATOR <br />ry <br />APPROVED BY: OC f V�( <br />CHECK if BILLING ADDRESS <br />FACILITY NAME�� <br />. <br />�-Y �.._.. <br />�4r <br />_�_.. _.._.I <br />SITE ADDRESS43 )1 <br />OCOfY' <br />f <br />► UY V "_1.�.� �(�JJ <br />reet NIUumI ber r-ecton <br />eet NaW. <br />Cit Zi Code <br />HOME or MAILING ADDRE S (1 Different from Site Address) <br />Payment Date <br />Payment Type <br />Invoice # <br />r t Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #i EXT. <br />act) r <br />APN # <br />LAND USE APPLICATION # <br />PHONE 92 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR v V CI CHECK if BILLING ADDRESS <br />BUSINESS NAMP PHONE# Ems' <br />HoMF or MAILING ADDRESS n� 1 t,/� FAx# <br />i .CITY 11 /1� STATE ZIP <br />j BILLING ACKNOWL ,DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledbe that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity WE.! be billed to me or my business as identified on this form. <br />a 1 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, S TE and FEDERAL la. ..�/� <br />APPLICANT'S SIGNATURE: �lWv DATE: U C2t O <br />MhiXA19£it n_ tYl7r�T.r: 1d?�bt[�RE7FJ?_: ANT. ,GI_ C lX�- <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 <br />above site address, hereby authorize the release of any and all results, geotechnical datatand/or environmental/site assessment <br />inforn{atioit to the SAN JOAQUIN COUNTY ENVIRONMENTAL HGAI_TH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />`i' <br />PAYMENITYPE OF SERVICE REQUESTED: (�(S j <br />COtMENTS: <br />END 48.01-025 SERVICE REQUEST FORM <br />RECEIVED <br />AUG 2 7 2010 <br />SAN JOAQUIN COUNTY <br />-ENVIRONMENTAL <br />u,EALITH D`=PA.RTMENT <br />APPROVED BY: OC f V�( <br />EMPLOYEE#: 0_32 <br />d <br />DATE: fi 77 (D <br />ASSIGNED TO: � ` <br />EMPLOYEE #: T z <br />DATE: -0 <br />2 � <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: 2� Q <br />Fee Amount: ��_ <br />Amount Paid <br />C7-0 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check #s g' <br />Received By: <br />END 48.01-025 SERVICE REQUEST FORM <br />