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SAN.TOAQ UI COUNTY ENVIRONMENTAL HEALTIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE ST# <br /> OWNER/OPERATOR <br /> nR � CHECK If BILLING ADDRESS <br /> FACILITY NAME/ <br /> SITE ADDRESS G �jGnfif'CCl 9��j3(p <br /> ` o Street Number Direction t Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY 7-0 <br /> STATE ZIP 'r r Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# 'ET <br /> Z-1 <br /> I► -9 2S Q S Co <br /> PHONE#T EXT. BOS DISTRICT _ FCA7 CODE <br /> 03 Co 7 0 20 6-%"- .S; 6 Co(S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ► <br /> CITY 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 610M �, �� DATE: 3 <br /> 16 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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. <br /> TYPE OF SERVICE REQUESTED: f.ZS'7r Go N s 1 e-L-7-X- PZ o,,%-) PAYM EN <br /> COMMENTS: rJE- 114) <br /> JUL - 3 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Te}t✓C i �O EMPLOYEE#: ©32 DATE: +7 <br /> ASSIGNED TO: EMPLOYEE#: -2- -D DATE: —7 <br /> Date Service Completed (if already completed): SERVICE CODE: 0("/ P I E:/ 2-3 d <br /> Fee Amount: s Amount Paid , 5 Payment Date <br /> Payment Type ✓� Invoice# Check# ` ✓1 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />