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MAY -26-2009 17:0892546211352 P,02,1112SAN JOAQ <br />UIN COUNTY ENVIRONMENTAL HEALTH DARTMENT <br />SERVICE REQUEST <br />Type of BUSIneSS or property <br />FACILITY ID # <br />SERVICE REQUEST # <br />service' �-�a- -I,© r� <br />a <br />OWNER / OPERATOR <br />CHECK If BILLING AbbRES4� <br />FACILITY NAW Qie,/ <br />SITE ADDRESS <br />[ C7 4f Y7 I^ `` <br />C �Gl b �� Ifd <br />1 / <br />�7 OG 7'" 0,-) <br />3treot u <br />etlon <br />' <br />Stree! Name <br />ctty. <br />B Co e <br />HOME or MAILING ADDRESS pf Ialffarent from SNte Address) <br />-.$treat Number <br />suaot NEWO <br />CITY <br />BxATt ZIP <br />PW0NE#1 Exr. ApTM �I <br />LAND USE APPLICATION # <br />1?4 ) 93'2- - 7 <br />PHONE#2 EXT, <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />KIEQ FrSTOEi cHECK 1f BILLING AODRE& I� <br />W1 I� v� � e <br />G�� F`1 S c') <br />BUsINEBS NA1NEret- ! pe-- co (,a urn ExT. <br />Fi01UlN' or MAILING ADDRESS FAX <br />I /ilp a ! Y2 ('fm-) <br />CITY Ie.QS�i]1-I'�t`1 T STATE zip ✓� a'(Q , <br />U11,L]INC, ACKNOW .EMENT: I, the undersigned property or business owner, operator or authorized Agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL 14EALTH DL'PARTMCN r hourly charges associated with this project <br />or activity will be billed to nic or ray 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, STA' pc andEDERZltd'—F— <br />APPLICANT'S <br />SIGNATURE- a'(DATE..:,%-��r t.4' t" J, <br />PROPERTY/BU51NESS OWNER❑ OPERATOR/ MANAGER OTHERAUTHORIzEDAGENT Rd <br />#'APPLICANT is not the AIL81proof of authorization to sign is required Title <br />AUTHORTZ N 'ro RELEASE N ORMATION: When applicable, 1, the owner or operator of the propel ty 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 ENviPLONMENTAL HEALTH DEPARTMFNT as soon as it is available and at the same tiQne it is <br />provided to me Or my representative. <br />TYPE OF SERVICE REQUESTED: Pe I'tr <br />COMMENTS'1T I VE D <br />• , :) � noart <br />ACCEPTED �Y: EMPLOYEE M DATE:JID C1, <br />ASSIGNED TO:EMPLOYEE#: DATE: <br />Date Service Competed (If already compiatad): SERVICE Cope: PIE; <br />Fee Amount: Amount Paid �' 6 Payment ate <br />Payment Type Invoice# Gheck#���3 Re eivedBy:)� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />DEVISED 11/17/2003 <br />TOTRL P.02 <br />