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SAN JOAQUIN*FNTY ENVIRONMENTAL HEALTH D RTMENT <br /> SERVICE-_FQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Ty a of Business or Property g 0 Q's-8, <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME C`c a- h <br /> �, r \\ I <br /> SITE ADDRESS V[ ` 1 �j l C1Io <br /> I <br /> � <br /> Street Number DI.-'on t Na e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE zip <br /> CITY <br /> PHONE#I EXT• APN# LAND USE APPLICATION# <br /> G t! a GO <br /> J <br /> Ext BOS DISTRICT LOCATION CODE <br /> PHONE#T � t <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` i�y� I rq CHECK if BILLING ADDRESS❑ <br /> l PHON l C� I E� <br /> BUSINESS NAME <br /> F n�HOME Or MAILING ADDRESS <br /> STATE n 4 ZIP <br /> CITY \C ` <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,Stand rds, and FE laws. f <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Title <br /> If APPLICANT is not BIL NG ARTY proof of authorization to sign is required <br /> d at the <br /> AUTHORIZATION TO RELEASE IN ATION: When applicable, Idata and/or environmental/site rator of the property oc assessment <br /> above <br /> above site address, hereby authorize the release of any and all results, geotechnical <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. (A. 9T 411e�—Iao F i—F <br /> TYPE OF SERVICE REQUESTED: = <br /> COMMENTS: f' <� T �'` ` " <br /> ECEV*ED <br /> R <br /> A-° v OCT 2 2 2009 <br /> SAN <br /> �IJOAQUIN <br /> ENTAL <br /> EMPLOYEE#: '�21 DA'"I" Q el <br /> ACCEPTED BY: (r)L.1 V� 9-Ac <br /> EMPLOYEE#: C) DATE: (O 0 <br /> ASSIGNED TO: �J A- L'( <br /> DaOSService Completed (if already completed): <br /> SERVICE CODE: Q PIE: oZ 3 <br /> Feunt: cK� Amount Paid aPayment DatebPaType �' S <br /> Invoice# Check# Received By: <br /> 49 116'5 130 SR FORM(Golden Rod) <br /> EHD 48-02-025 / <br /> REVISED 11/17/2003 3q5 <br />