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SAN JOAQ*CouNTY ENVIRONMENTAL HEALAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FAC <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />T4s STyQ-�10NLziLw—oPlp <br />PHONE# <br />gt <br />870-3*0 <br />1,:5 Poo <br />(5 '3 / (-, <br />OWNER I.1323MOEM <br />C©nv (eLAc-,e- L LO , <br />CHECK If BILLING ADDRESS ❑ <br />FAciuTY NAME Ct'-x vAv' <br />C t Lt -7 ( <br />ZIP q-5-62/ <br />SERVICE CODE: <br />SITE ADDRESS 1 !L/O <br />Fee Amount: '� <br />, , / <br />0&4 / /�/✓ _ / <br />/J/ �f <br />1 Payment bate ,r-/15 � -r <br />` <br />�" <br />Invoice # <br />O 72oq <br />�•Zip <br />Street Number <br />Di <br />t <br />t e <br />Code <br />HOME or MAILING ADDRESS (if Diffomnt <br />from Site Addres s) <br />a"cC <br />Street Number <br />Street Name <br />CITY <br />/1-4m rapt <br />STATE ZIP <br />PHONE #1 <br />(1/6) 26-7-1)2o <br />Err. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR� <br />R EC - <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME�LeSr� l2 _ C <br />el..Y� <br />ACCEPTED BY: <br />PHONE# <br />gt <br />870-3*0 <br />HOME or MAILING ADDRESS /� F <br />/�J� <br />ASSIGNED TO: <br />SAX# <br />72 -- <br />CITY W 5 �,2��� �� <br />STATr1 /I <br />ZIP q-5-62/ <br />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, STAXE and FEDEM laws. <br />APPLICANT'S SIGNATURE: 17YDATE: `09 <br />PROPERTY / Busmss OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED <br />If APPLICANT is not the BILLING PAR TI 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. pA:Y l\A ENT <br />TYPE OF SERVICE REQUESTED: <br />R EC - <br />COMMENTS: <br />MAY 1 5 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />OFALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE. <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E. IJ <br />Fee Amount: '� <br />Amount Paid <br />f�315 D -0 <br />1 Payment bate ,r-/15 � -r <br />Payment Type <br />Invoice # <br />Check # <br />Re eived By: . <br />EHD 48-02-025 ��'l�- Y� d l� G `f J SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />