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SAN JOAQUOOUNTY ENVIRONMENTAL HEAL'TIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Wj4G- <br /> OWNER/OPEUm <br /> R <br /> ot? bI( �` CHECK if BILLING ADDRESS E] <br /> FACILITY NAME n AM <br /> b 5 b <br /> SITE ADDRESS n„ _ } � /1, _,. n 9 52--61 <br /> OggStreet Number lection Name Cl l r Code <br /> HOMEyM�AILI ADDRESS (If Different from Site Address) <br /> V o ( Street Number Street Name <br /> CI T1� 1 �a �STATE 95Zip <br /> VI I <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> ( I ) 25�O <br /> PHONE V EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR ✓, <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS �1_, + <br /> BUSINESS NAME 'on �n i - n P # 2�Z r7 Q 2 E"r' <br /> HOME��,Qr JyA�I 1 A- I-C e � Ln <br /> ( # ) <br /> CITY IXJI ' /�„fuSTATE <br /> BILLING ACKNOWLEDGEMENT: 1, 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: ` O/f t9 <br /> PROPERTY/BUSINESS OWNER5�OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT,® GQ✓f�i�!G�+�-- <br /> If APPLICANT is not the BiLgNG 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: (.L ST <br /> COMMENTS: �Et/ <br /> otj N% Nn OCT 1 5 2010 <br /> �oAa�`Me-WA"Ni ENVIKUNIAN 1 HEALTH <br /> vp�'""E PERMIT/SERVICES <br /> ACCEPTED BY: t✓ LL EMPLOYEE#: C)32-1 DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2(p DATE: CO IS (v <br /> Date Service Completed (if already completed): SERVICE CODE: ( ?k' I <br /> P 1 E: :220 <br /> Fee Amount: ?�Lo(o , Amount Paid b L _ Payment Date 0 S/lo <br /> Payment Type Invoice# Check# L(; S 5 S Received By: jyZ}._ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />