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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />6-11 -C /7/,/ G <br />PHONE# EXT. <br />�t6 S7o - 388 0 <br />HOME or MAILING ADDRESS <br />Z S/ EI.S xaie6r&7U A16 <br />-leS6�7. le/G A/dv dG �ccP <br />OWNER/ OPERATOR �2c 2705 b l c e � <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DDRESS <br />SITE ADDRESS <br />(� OkoAy elft to <br />S /�7 ► <br />ACCEPTED BY: <br />/4d 3 Street Number <br />Direction <br />,flag <br />Street Name <br />EMPLOYEE #: <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS <br />SS((if Different from Site Address) P-603 <br />aT4n &i% nt Y <br />f A4 t /V d /QjQi00A) <br />Street NumberStreet <br />Name <br />CITY E',-Iftv 044-10AJ <br />STATE Vg5-5 <br />PHONE #1 EXT. <br />APN # <br />Check # y Z <br />LAND USE APPLICATION # <br />(7/4) 267-02o <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /J��r� 1 a!t! e7S <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME I�/C <br />COMMENTS:�kI/"/Y14 <br />PHONE# EXT. <br />�t6 S7o - 388 0 <br />HOME or MAILING ADDRESS <br />Z S/ EI.S xaie6r&7U A16 <br />-leS6�7. le/G A/dv dG �ccP <br />FAX # <br />X9/6) 372 - 9 3 7< - <br />CITY / es 5**c aPof c-x-im <br />STATE ZIP Q`/- q/ <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: (i`-- DATE: 7- <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ID COA/7X*dlr�K <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: <br />COMMENTS:�kI/"/Y14 <br />-leS6�7. le/G A/dv dG �ccP <br />6�zb/vy <br />RECEIVED <br />"^ <br />JUL - 2 2009 <br />N JOAQUIN COUNTY <br />ACCEPTED BY: <br />EMPLOYEE #: <br />D1 . <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE. <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />, <br />Amount Paid's .— <br />Payment Date <br />Payment Type C <br />Invoice # <br />Check # y Z <br />Received By: <br />C111-1 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />