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SAN JOAQUIN IPUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> A � � PF—RA. i"l 1 CHECK If BILLING ADDRES <br /> 4 <br /> FACILITY NAME <br /> SITE ADDRESS •779 <br /> Street Number Direction W� Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (Zcc) .err- (o - S Doc> <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (nor) S4 r 5 11 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME�►^, L" '—` PHONE# ExT. <br /> HOME or MAILING ADDRESS d,• �� FAX# <br /> '7--7 0 1 5 4 3.- I O'dr <br /> CITY ��A�C.-FZAM "-r C) STATE �` ZIP (�S ty <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:_ ��� DATE: ;Z- ' E ' cq <br /> V <br /> ! <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ld S�O1C�.0-T 1�^LAi�R��►�SZ <br /> IfAPPLICANT 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: PAYME <br /> COMMENTS: <br /> FEB 0 5 2009 <br /> S ENJOROUIN COUNTY <br /> I1E,gL7H OEPARWENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: <br /> Fee Amount: `� a Z Amount Paid Pay t Date <br /> Payment Type Invoice# Check# O Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />