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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 397t S�' ' q I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEf T F� <br /> f`-4t l'4 ' " -''1�17et-:� l(,>� 1...• �ra� <br /> SITE ADDRESS <br /> l Street Number Direction Street Name Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I) � E., APN#�CAD � f-0 �� LAND USE APPLICATION# <br /> (12-e I <br /> PHONE#2 EXT. SOS DISTRICT LOCA ODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR - 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.• <br /> HOME or MmuNG ADDRESS FAx# r W <br /> OX, <br /> CITY 55-!C�1+-1PIA:_t .._, STATE , 7 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,Standar,(STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU '-4 — DATE <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER d OTHER AUTHORIZED AGENT 6T r si u <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sigh 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: Lk ST / tat ,J 6- 4—g0A-( r2_ HAYMENT <br /> COMMENTS: SEP 16 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ©(4 LJEMPLOYEE#: C:)3 Z( DATE: C? t to(0 <br /> ASSIGNED TO: �� EMPLOYEE#: 2(P7 0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> C) <br /> Fee Amount:43 S-f1 J Amount Paid tf3 -b Payment Date 14 1 <br /> Payment Type LX I Invoice# Check# c�3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />