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SAN JOAQ OUNTY ENVIRONMENTAL HEALTSPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I, a <br /> OWNER/OPERATORrx ' <br /> CHECK if BILLING ADDRESSP31. <br /> FACILITY NAME <br /> sl �N_S Co 1.�� CLQQ <br /> 213cv1� bra C.�Xa� qso� <br /> Street Number Direction v Street Name Ci Zip Code <br /> HOME or MAILING ADPRESS (if Different from Site Address) <br /> 6A W\C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• # LAND USE APPLICATION# <br /> (207) �3 - 13 0 APN(23- 1Jv - tv <br /> PHONE#2 EXT. BOS DISTRICT i LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ve^_)0 �z CHECK If BILLING ADDRESSO <br /> BUSINESS NAME V PHONE# EXT. <br /> P - IS3 <br /> HOMEOr (LING ADDRESS FAX# <br /> 0°, o rb,c 1 (It ff.) 170`( - 1 <br /> CITY sc"� STATE ZIP 6 <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 a work to be per d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 0RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING 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 t0 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: t,.( S TT <br /> COMMENTS: R <br /> c�-P�-(rz- I( 5w^P S^J fi-R_--r r3 0 7- FEB g 2010 <br /> (REQ -i (2 UC___eS 020X �t-S` _A /S Cy , N ENO QukN COUNV((Al- <br /> SA <br /> HEAI-TH DEPARWENT <br /> ACCEPTED BY: cxLl EMPLOYEE#: 3 Z� DATE: Z <br /> ASSIGNED TO: {P 'A EMPLOYEE#: L( 61 3 DATE: cl t Q <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 22(_) <br /> Fee Amount: -2 t,5;�t� Amount Paid �3L,'S Payment Date /(0 <br /> Payment Type Invoice# Check# �'� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />