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SAN JOAQUIIWOUNTY ENVIRONMENTAL HEALTHa.:PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />BUSINESS NAME <br />F3'Z ' A -CE <br />SERVICE REQUEST # <br />HOME or MAILING ADDRES <br />FAX # <br />— <br />5 <br />(! ) - a S 41 D <br />STATE ZIP ' I <br />CITY e - S i SA -r— a 4 `Alin <br />OWNER / OPERATOR <br />(/ <br />S � O <br />ACCEPTED BY: ©L l v./ 1✓t � <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Lob <br />DATE:1244 G; <br />ASSIGNED TO: Q Y I- -- <br />SITE ADDRESS <br />1I :ZS <br />w <br />�.ocl<F'drz� si <br />Date Service Completed (if already completed): <br />LOD1 <br />95Z�� <br />Street Number <br />Direction <br />Fee Amount: 4 3 i. f . 00 <br />Street Name <br />PaymentDate/aI <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />- r <br />CO 37 n© -,oz <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />( )Lf <br />2 -- <br />CONTRACTOR <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />In <br />CHECK If BILLING ADDRESS <br />C VV ir- PI, <br />BUSINESS NAME <br />F3'Z ' A -CE <br />PHONE # ExT. <br />r <br />HOME or MAILING ADDRES <br />FAX # <br />— <br />5 <br />(! ) - a S 41 D <br />STATE ZIP ' I <br />CITY e - S i SA -r— a 4 `Alin <br />I/ <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 1 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 and FEDERAL laws. <br />I <br />APPLICANT'S SIGNATURE: � DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is require t� 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: u S'� <br />t2--E-•7yg-0 F CT- <br />phvuFNT <br />COMMENTS: J15%nIEtZ <br />RECEIVED <br />DEC - 4 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ©L l v./ 1✓t � <br />EMPLOYEE #: Z-- � <br />DATE:1244 G; <br />ASSIGNED TO: Q Y I- -- <br />EMPLOYEE M Lf <br />DATE: (1-J4-(09 <br />Date Service Completed (if already completed): <br />G <br />SERVICE CODE: (8 <br />P If E: 23 O <br />Fee Amount: 4 3 i. f . 00 <br />Amount Paid 3 qs , 00 <br />PaymentDate/aI <br />1 l0 () <br />/ <br />Payment Type CAE �� <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />