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SAN JOAQUIN COUNTY ENVIRONMENTAI.HEALTH DEPARTMENT 'r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ PERATOR <br /> CHECK If BILLING ADORESS� <br /> FACILITY NAMESITE �J /�, /� <br /> 2goD3/S Val l /COQ //Nra - / <br /> / Street Number action Street Name Zip Code <br /> Hwiii:or <br /> MAILI O AODRES (If Different from,Site Address) <br /> Street Number r L' r 460 Vtrget Name/ <br /> CITYT-hD �J STATE Z 6 <br /> PHONE#t E-- APN# /�'- LAND USE APPLICAHON# <br /> RSR - 381 00/ -/GO -O / A--//DO/3�?- /19S <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ,r <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ///�O� -/.P— X- \ p CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME �j+�//J v l� PHONE Ezr. <br /> z 3 <br /> HOME or MAILING ADDRESS <br /> Da +e FX# <br /> ""� <br /> CITY O �/ / �O STATE ZIP <br /> BILLING ACKNOWLE GEMENT: 1, 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 wdl 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: Z — 2 4 — <br /> PROPERTY I BUSINESS OWNER OPERA-16R/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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT assoon 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: /2?✓iI RECEIVED <br /> FEB 2 7 2009 <br /> m G G'CE'7'7tJ \ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S?�7i PIE <br /> Fee Amount: W Amount Paid a l D — Payment Date Z 2? 0 <br /> Payment Type Invoice# Check# 3() Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />