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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS CI <br /> Street NumberF 'io" <br /> V S l Street Name— � cift <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT, API# LAND USE APPLICATION# <br /> ( zay, 32°1 777J - .Z8U - (DeA C7 <br /> PHONE#2 EXT_ t3OS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR C [ _ _ (; f _ ^ ^ <br /> ►/� u�x-�,p �-Gv" 4 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> HOME or MAILING A D D R E S S + r FAx# <br /> CITY rte, STATE zip Z 'z <br /> BILLING ACKNOWLEDEEM ENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMFNTAL Hr;ALTli DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Siandards, TE EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AtTTHORIZED 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 <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 HEAuni 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: <br /> COMMENTS: «-//e 14 f f R E C E I V E D <br /> DEC - B 2009 <br /> SAN JOAQUlN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED Y: EMPLOYEE#: 7, DATE: ] '2- <br /> ASSIGNED <br /> ASSIGNED #: <br /> Date Service Completed (if already completed): SERVICE CODE: 2 PIE: G1 <br /> Fee Amount: Amount Paid 'W-d, 3 0 , Payment Date L <br /> FPayment Type (/ Invoice # Check# `D Received By: �— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />