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SAN JOAQUIN COUNTY ENN'IRW01ENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sleoos9z63 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS n�/�6�/ s n � <br /> StFebt Number Df n Nqreel Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number _ Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# <br /> (/ — v <br /> PHONE#2 C/ EAT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESSC�Ad_'C_� � I�1 -1 a I �•\` <br /> PHON # —/ EXT. <br /> BUSINESS NAME <br /> HOME Or MAILING ADDRESS FAx# CJ <br /> ( 1 � <br /> CITY STATE ZIP t n <br /> V i <br /> BILLING ACKNOWLEDGEINIENT: 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 will be billed to me or my business as identified on this form_ (n <br /> I also certify that I have prepared this plication d that the work to be performed will be done in accorda ice with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa s TATE an I uk.RAL laws. <br /> APPLICANT'S SIGNATURE: \ DATE: <br /> V <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/INIAN R 11OTHER AI'THURIZED AGENT I t <br /> If APPLICANT is not the B11.LLVG PARTY /hoof of authorization to.sign is required Title <br /> AUTHOR17 iLTION 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 an(Lor environmental/site assessment <br /> infOtlnition to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARIMENT 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: Lmute w e- <br /> G(9'✓f <br /> COMh1ENT$: <br /> v G'cY'��'1�470't/ QOM f tIS� �Tf�ie��! Zo �l-S7/f-�y <br /> PAYMENT <br /> `�'4r y� �(/�• RECEIVED <br /> � nz�Zt��r � ��nom' � _� <br /> �� f� � ;,, ,,H• �� �3 ¢� SEP - 4 2009 <br /> � <br /> ACG PTE BY: 5WH EMPLOYEE#: DATE"ii <br /> T�._ EA E ME-.- <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 47— <br /> P!E: 27 1 <br /> Fee Amount: 1��, Amount Paid /S Payment Date <br /> Payment Type " �- Invoice# Check# Received By: , <br /> EHD 48-02-025 Cz04?j -76?7 Aie �y�&G� SR FORM(Oblden Rod) <br /> REVISED 11/17/2003 <br />