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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT>LPEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> wwelz S4-00sT712— <br /> OWNER/OP <br /> 12OWNER/OP TOR \ <br /> CHECK 11 BILLING ADDRESS <br /> u e,e Ila-47,6F L4,11 AjEQo c, <br /> FACILITY NAME <br /> �s s/ t7� o c o �Acrcrr <br /> SITEADDRESS /O,G7 N ,TA Cog BRACK .SOP/ 9522 <br /> Street Number I Direction I Street Name CIN Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> •Q . 60X Street Number Street Name <br /> CIN STATE ZIP <br /> 5T, yELEAiA CA 9¢574-024'0 <br /> PHONE#1 En. APN# Oil- O Q'Q_ e�3 LAND USE APPLICATION# <br /> ZA <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR D0^1 <br /> cl-lE:5fvF-1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> C)4ES/4E Co/VSal-7-1n/C L. /_ 03 <br /> HOME or MAILING ADDRESS FAX# -- <br /> • Q . 00K 3 czo7 ) <br /> CITY G� STATE CA ZIP <br /> Vl <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 /> 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,S and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ��3— Lo <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El HER AUTHORIZED AGENT 10 <br /> If APPLICANT is not the BILLING PARTY proof of autl rilation 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. <br /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> N/T/tATELOAD/Al SO/LSU/TA&/za TUDIES —CP T/C <br /> COMMENT <br /> I �,� r',*5n�,,N0 V - 3 2009 <br /> SANViROUIN COUNTY <br /> Q HEALTH <br /> ,• DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M Q�Z/ DATE: <br /> ASSIGNED TO: y�.(�,Q l ry EMPLOYEE#: s3� 'a DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SSS P/E: a/iO <br /> Fee Amount: S75 DL7 Amount Paid _ — Payment Date �� Q <br /> Payment Type Invoice# Check#�'p(Q R ei' of ey <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />