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—�11 i i Buil r inv1'11r1r 1v 1 AL IIL'AL1111JEFAXI A NT <br /> SERVICE REQUEST <br /> Ape of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I r <br /> O NER/OPERATOR <br /> CHECKIfBILLINGADDRESSCJ <br /> FACUIT NAME t I <br /> _ _ <br /> SITE ADDRESS <br /> StrefkM eXrectidrlAi' Ha w ns= ..A "� ' <br /> 1 . J <br /> I COX26 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExTAPN# LAND USE APPLICATION# <br /> OL <br /> PHONE#2 ExT. <br /> BOS DISTRICT LOCA71 ON CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> [BUSINESS <br /> EQUESTO <br /> CHECK if BILLING ADDRESS <br /> NAMEI <br /> ✓( PHONE# Exr. <br /> i <br /> HOME or MAILING ADDRESS j F)I All FAX# <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 or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this appy a'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S Tt and FEDERA) laws. <br /> APPLICANT'S SIGNATURE: d DATE: <br /> PROPERTY/BUSINESS OWNER❑ <br /> OPERATOR/MANAGER ❑. OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BffLUNGPARTY 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: S'r 4,F— F/ 7 <br /> COMMENTS: AY M ENT <br /> R <br /> APR -8 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: (OCt [ DATE: <br /> IP�4 EMPLOYEE#: 3 L! 8//U <br /> ASSIGNED T0: k-L1-L EMPLOYEE#: L .3 b DATE: T !� <br /> Date Service Completed (if already completed): SERVICE CODE: 19e, P I E: <br /> Fee Amount: s�p J Amount Paid Payment Date (O 1 D <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 :., <br /> REVISED 11/17/2003 SRJ Of (l;oidn Rod) <br />