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SAN JOAQU) oUNTY ENviRoNMENTAL HEALTHARTMENT <br /> ' J SERVICE REQUEST or <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ;OrmQ. �-z� 3`l s L/ SlZov 5 (,3X10 <br /> OWNER/OPERATOR��aa'� <br /> So �Y I � C©i Llt i•/ ��-� � 5��1/��S 1] � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SAS.:► :Z 6c"LA L;ry Qu Q L_xz LAJC)l-ie-s <br /> SITE ADDRESS ( &10 Phi SR9C�1�T�+� �� I <br /> Street NumberDirection SfteetName city ZiD Code <br /> HOME or MAIUNG ADDRESS (if Different from Site Address) fJ/A- ------ <br /> t-j/A Street Number Street Name <br /> CITY STATE ZIP <br /> whk — <br /> PHONE M APN# LAND USE APPLICATION# <br /> ( ) <br /> 155 1130 62. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> R:EQUESTOR --SM5'9P N '8 44L 7C_)O' CHECK if BILLING ADDRESS <br /> BUSINESS NAME Pww# ' <br /> $PRrI E <br /> (20!j) <br /> HOME or MAILING ADDRESS FAX# <br /> 170 (Y%A"-XV (ul ) 34,-7 <br /> CITY .mss, L-0 o STATE �i ZIP �9 �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 d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ©II Z 31.P W? <br /> PROPERTY/BUSINESS OWNER❑ 01`16/0R/MANAGER ❑ OTHER AUTHORIZED AGENT J CDL—� <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 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: LILS-T— G F- C'T <br /> COMMENTS: <br /> Comply L4-.7z-r14 POA-sg- a e42 "p6aA-of. TV-J <br /> Cp28RECEIVED <br /> JAN 2 6 2009 <br /> CAKI <br /> ACCEPTED BY: C l L,E t 44- <br /> EMPLOYEE#: 3 7, H DE E G <br /> ASSIGNED TO: (�,d�/ &-- EMPLOYEE#: /1�(- �/ DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: , P/E: 2_3 C�' <br /> Fee Amount: j j ,�) Amount Paid J— _ Payment Date / a <br /> Payment Type Invoice# Check# 4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 1/1 71200:1 <br />