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SAN.TOA*COUNTY ENVIRONMENTAL HEAL <br /> 1WEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACI�LIT�Y/ISD# SERVICE REQUEST# A <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS[]-�v v o�1 use" <br /> FACILITY NAME <br /> SITE ADDRESS r q 60 [ <br /> V l i `'/�- Ist— <-7-y�� <br /> Street Number Direction ` TGl r Name 1 Ci i A <br /> HOME or MAILING ADDRESS (if Different from Site Address) �o�X <br /> Street Number Street Name <br /> CITY a STATE zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> CTcLCL ( •-1��3 b' <br /> HOME or MAILING ADDRESS6 FAX# <br /> �L VA (4(W ) Wl- 0 :4 <br /> CITY "S�V - (�S k STATE 0A zip 9M,— <br /> BILLING <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 /> 1 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: yU �,�,; y1l DATE: G /1 S" awl <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTS LOW l(alj!ce &(4it er <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: St i�� CjN <br /> COMMENTS: ip�vL�c�� 1s �t � [�ECEIVEp <br /> V C7r L JUN 17 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVION <br /> HEALT}iDEPgRTME <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: sd DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: d <br /> Fee Amount: `n Amount Paid Payment Date � 1 v <br /> Payment Type Invoice# Check# gecelVed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />