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SAN JOAQUIr'-`'JUNTY ENVIRONXENT-.AL HEALTI'"'EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S SERVICE EQU�#p 3 <br /> � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS -- - VV %� <br /> .,..o.....__.__r Direction !Ci T SUe A Name city de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> ?'-J. Z Z •^� -7 Street Number <br /> Street Name <br /> CITY /„_ 95,766 <br /> `,(i A. STATE ZIP <br /> PHONE#1 )YJ`� ✓T � APN# LANDUsEAPPLICAnON# <br /> O9) 7V3- /-41-6- nlr - d(o-off p-o$oo32-3 /YI.S <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> 0/w/ ) 3,7tl,:SOO& Z 11 '� c <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> r c:• <br /> REQUESTOR T / CHECK If BILLING ADDRESS r <br /> BUSINESS NAME b PHONE# Exr. <br /> ( <br /> HOME or MAILING ADDRESS FAX# <br /> /V'25 ( 1 <br /> CITY J6 ./_ STATE ZIP <br /> ✓C/ co \1 <br /> BELLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, 11 <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 1\� <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 !v <br /> COUNTY Ordinance Codes,Standards,ST TE FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ R/MANAGER OTHER AUTHORIZED AGENT❑ ' <br /> If APPLICANTisn h B/LL/NGPARTYproof ofauthorization tosign isrequired 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 JOAQUQN 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 /> TYPE OF SERVICE REQUESTED: S4-4f-ACE <br /> COMMENTS: <br /> PAYMENT <br /> q(�Oo RECEIVED <br /> 2BY: <br /> MAR 6 2009: Q C( v*[--' 14—A SAENVIRONMENT EMPLOYEE#: �! I DATE: <br /> ASSIGNED TO: (--(F_,01/UA-- EMPLOYEE#: S's/cDATE: 3 tWOC <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount: , Amount Paid O, D Payment Date 3/t, ) Q <br /> Payment Type �/ Invoice# Check# �rj(G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />