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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />r _ <br />BUSINESS NAM V12 ® <br />FACILITY ID # <br />SERVICE REQUEST # <br />(Ax #� <br />CITY 5 ST ZIP �7 f - <br />&L(-3 <br />-00S74�SJ� <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />SAN JOAQUIN COUNTY <br />FACILITY NAME <br />6;911 <br />A <br />SITE ADDRESS <br />C `� <br />✓7 Street Number <br />Direction Street ame Ci Zi Code <br />HOME r MAILING ADDRESS (If Different from Site Address) -7 M �` Q Y/� <br />ZeZZIN (i <br />Street Number Street w e <br />rr( <br />CITY <br />ATE ZIP <br />DATE: S �/ <br />G/#7Tt <br />PHONE #1 <br />ExT• <br />APN # <br />LAND USE APPLICATION <br />Amount Paid <br />Z) 2- <br />to ZS U <br />PHONE #2 <br />EXT. <br />DISTRICT <br />LOCATION CODE <br />( ) <br />Ir6s <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Am I <br />CHECK if BILLING ADDRESS <br />{/ <br />r _ <br />BUSINESS NAM V12 ® <br />PHONE # ExT. <br />HOME Or MAILING ADDRI�8*O <br />JJvv�f --moi <br />(Ax #� <br />CITY 5 ST ZIP �7 f - <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 />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, Standard STATE and FE RAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER El OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT (�G`�3r✓i�j :,` <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 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: <br />COMMENTS: <br />RECEIVED <br />JUN 2 5 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: t <br />EMPLOYEE #:v% <br />3' J <br />DATE: ZS U q <br />ASSIGNED TO: .r <br />EMPLOYEE #: <br />q & 3 b <br />DATE: S �/ <br />Date Service Completed (if already completed): <br />SERVICE CODE: IF 1P <br />P I E: <br />I <br />Fee Amount: 3S t�"L7 <br />Amount Paid <br />Payment Date <br />to ZS U <br />Payment Type <br />Invoice # <br />Check # <br />C� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />