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SAN JOAQU OUNTY ENVIRONMENTAL HEALTI ',PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUES <br /> i4�9 '00 <br /> OWNER/OPERAT R <br /> CHECK If BILLING ADDRESS LSI <br /> �104 <br /> FACILITY NAME <br /> 0✓i 7'e-p ft <br /> SITE ADDRESS <br /> Street Number I Direction Street Name C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> `—� Street Number Street Name <br /> CITY STATE ZIP <br /> 7-,"r4C el'/ ---7 7 P <br /> PHONE#1 EXT. TAPN 8 LAND USE APPLICATION# <br /> PHONE#Y EXT. BOS DISTRICT I LOCA TI NCODE <br /> ( y ) U ' "r� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> f �� v e`C n U O . D Y $ CHECK If BILLING ADDRESS❑ <br /> e S <br /> BUSINESS NAME T C I t0� PHONE# ExT' <br /> V,qi, t✓ea ^�..tJ 5 `% <br /> HOME or MAILING ADDRESSki FAX# <br /> _ <br /> CA `7 1.��E%r �E� (Z,- ) VE V- 3s G S <br /> CITY 15 c C 4 7-C N STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,STATEandFEDERAL laws. <br /> APPLICANT'S SIGNA7'WllQE: 77,- � nn DATE: /,2-//l c-� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT is not the BILL/NG PAR7T,proof of authorization 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. Id 4:T <br /> TYPE OF SERVICE REQUESTED: �� t"I— P IVED <br /> COMMENTS: <br /> DEC 2 9 2008 <br /> SAN JOAQUM COUNTY <br /> HEALTH DEPART ENT <br /> ACCEPTED BY: UL l EMPLOYEE#: Q 3 DATE: `2-12- <br /> Z q <br /> ASSIGNED TO: V 0.-J eL c.t E EMPLOYEE#: 8'3/ DATE: Z l Joe <br /> Date Service Completed (if already completed): SERVICE CODE: I E: <br /> Fee Amount: ,ry s v Amount Paid 3 I s Payment Date <br /> Payment Type Invoice# Check# ac� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />