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n <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER!OPERATOR CHECK if BILLING ADDRESS❑ <br /> F9455D /Wcr,4- Jl-. <br /> FACILITY NAME <br /> SITE ADDRESS 0+v4ber <br /> j� , <br /> Street NumDirection Street Name city ti Code <br /> HOME Or MAILING ADDRESS III Different from Site Address) <br /> Street Number Street Name '. <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> } 60l-7973 Oy/- 3. o-- 24, PA- pS-3c)7 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> Ifr CONTRACTOR/ SERVICE REQUESTOR2.0 <br /> REQlJESTOR1 141 <br /> ,�+ `) CHECK If BILLING ADDRESS <br /> BUSINESS.NAME hl++*►VN C MV�7 PHOS j '`oGt3.. EXT <br /> HOME Or MAILING ADDRESS •/^� O D�, Fes# 7 a�Z3 A <br /> P. Sar <br /> Z/90 1 ) �3tf <br /> CITY STATE ZIP <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 <br /> or activity will be billed to me Or my business as identified on this form. <br /> t <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,STATE an EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r �u'ro <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY 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 env ironmentaUsite'assess ment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time if is <br /> provided to me or my representative. <br /> 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIITIVED <br /> ���71Z ��� -t^ APR 2.2 2010 <br /> L.SC 9 U BAN-LbAQUIK caukrr <br /> oNm . <br /> / ENVIRDHMEtlTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q EMPLOYEE#: / (�i DATE. <br /> Date Service Completed (if already completed): SERVICE`CODE: P!E: <br /> Fee Amount: Amount Paid 0 6A Payment Date <br /> l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM olden Rod) <br /> REVISED 11/1712003 <br />