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r, <br /> SAN JOAQUwOUNTY ENVIRONMENTAL HEALTEOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> <W 71161 *5-2-1 SIMM&I a53 <br /> OWNER/OPERATOR / l <br /> 5, CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> �vyPvl <br /> SITEADDRESS //0,J So:Il A."el "441 A. 7--e c of <br /> 7 <br /> Street Number Direction 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 Exr. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Exr. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �l t /� J <br /> ` L i CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> L.c/� ' dd =. moi/✓ t r9C� �/6 ��/����'�� <br /> HOME or MAILING ADDRESS ^ / FAX# <br /> 30 S (9/6') 6 XJ <br /> CITY �"� e U STATE G 1 ZIP 9's-7-3 <br /> 7-3 y <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: <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILGING 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: T �{�, yC f PAYMENT <br /> COMMENTS: RECEIVED <br /> .�- Z-C% U G �' /s h' ivy��A ��,� NOV 0 1 2010 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ` t UE i F"'T EMPLOYEE#: �3 L/ DATE: i l 1 <br /> DATE: 1; ! <br /> ASSIGNED TO: t EMPLOYEE#: Z(� l v <br /> Date Service Completed (if already completed): SERVICE CODE: cl+8' P I E:2? b <br /> Fee Amount: cro Amount Paid - 3( �p O j) Payment Date L <br /> Payment Type �s�/}1 <br /> Invoice�# Check# Received By: <br /> EHD 48-02-025 n �'' "— oO " ' SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />