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• SAN .TOAD _N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property i FACILITY ID# / SERVICE REQUEST# <br /> COIN �( C kO-\ SNry :tt (90 2-v <br /> OWNER/OPERATOR <br /> 6 A I,(- O CHECK If BILLING ADDRESS <br /> FACILITY NAME n n A 2 C O (o O 2 <br /> SITE ADDRESS , ( / <br /> Y c Q m I�-`-2 Av e e.r e ✓n t�r`f e c-1- 11533 <br /> tO <br /> Str9st Numb., Inctio a I d <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN 0 LAND USE APPLICATION 0 <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR \ <br /> f_'i1 l C � /. I�ln O��e-S C-y�� (V�v Q"k ) CHECK If BILLING ADDRE33 <br /> BUSINESS NAME RVi S 1Qr\ /y� cl_ ^` C�1 / PHONE# Ems' <br /> HOME or MAILING ADDRESSFAX# <br /> 2-(0oO (5-10) 9 <br /> CITY SO Le O- O C STATE C '+ ZIP 9,L S- <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,Standard7STE1andd FEDERAL laws. <br /> 14 - <br /> APPLICANT'S SIGNATURE: DATE: - O <br /> �/, <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILGING PARTY proof of authorization to sign is required I 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 resentative. <br /> TYPE OF SERVICE REO D: pAyMENT <br /> COMMENTS: REC <br /> JUN 4 2008 <br /> SAN JOAONIN COUNTY <br /> ENTH nEPARTMF <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount PaidV Payment Date lf(Q <br /> Payment Type L� Invoice# Check# S / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />