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SAN JOAQU14OUNTY ENVIRONMENTAL HEALTH L ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &VM= �3 �© r � SCO S �; -7/ <br /> OWNER/OPERATOR <br /> V j t' CHECK If BILLING ADDRESS <br /> FACILITY NAME (`���� <br /> SITE ADDRESS !t?.. <br /> ber Direc -337 <br /> tion S �Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> a4�) tg - ��� _t�� <br /> PHONE#2 ExT• BOS DISTRICT LOCATIO CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � �v //tL <br /> CHECK if BILLING ADDRES <br /> BUSINESS NAMEPH ExT. <br /> //ISG �# <br /> HOME Or MAILING ADprEo �D'y- � � A& <br /> CITY (/' LSA STATE Cl+ QZIP9/!�-7 I-7 <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 /> 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: \Y Gl �L `'� DATE: ^J v 7 <br /> PROPERTY/BUSINESS OWNER[:] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILGING PARTY,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. <br /> TYPE OF SERVICE REQUESTED: �( S j I / ry /�a—� 1 �_ FJ\I ED <br /> COMMENTS: <br /> MAR 5 2009 <br /> SAN JOAQUIN COUN7Y. <br /> HFN,JIBONMF IAL <br /> TN DEPARTMEt4T <br /> AL <br /> ACCEPTED BY: Q L t V t EMPLOYEE#: 0'2, 2-A DATE: 3 <br /> ASSIGNED TO: /V EMPLOYEE#: U DATE: 3 S O C/- <br /> Date <br /> Date Service Completed (if already Completed): SERVICE CODE: j G L, P I E: _Z3 <br /> Fee Amount: - 1 'S C o I <br /> Amount Paid Payment Date 3 /rte 9 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />