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0 /b 00-P <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S20o(o02-ADS <br /> OWNER/OPERATOR . <br /> II CHECK If BILLING ADDRESS <br /> FACILITY NAMEI <br /> SITE ADDRESS I rlr IS � f4� /v/'�1` `Stree�er tion a 1 ' it l... I city I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EE-. APN# LAND USE APPLICATION# <br /> �� <br /> w `) ,O �U <br /> PHONE#2 XT• BOS DISTRICT 3 LOCATION CODE <br /> (� 4-72 9S8 Dc <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ?( �©/� 1 ( PHONE XT <br /> Z E . <br /> HOME or MAILING ADDRESS FAX# <br /> (�f�fi /off I <br /> CITY U1 STATE ZIP <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 th' applic i and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar AT and FERE laws. / <br /> APPLICANT'S SIGNATURE: DATE: L D <br /> PROPERTY/BUSINESS OWNER 13 R/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 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. 7 � T <br /> TYPE OF SERVICE REQUESTED: ^ RECEIVED <br /> COMMENTS: f� �/ rnQ- --fi—q / � /! I JUN 14 2010 <br /> �L(.( �7�, 1��t LI/l�/ �.)OAQUTN COUrm <br /> "t/J) EWRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Q i V E i EMPLOYEE#: .' 2— DATE: /_ r-0 <br /> ASSIGNED TO: fY tl`/Q u EMPLOYEE#: �!_•7 Q DATE: (�41 t� f 0 <br /> Date Service Completed (if already completed): SERVICE CODE: I( c�� Ph: 2_3 0 j <br /> Fee Amount: Amount Paid 3 S v Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ;5AVct--�CJQ�A <br /> 209 4k34 a-2� C6209 <br />