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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTSEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cl r <br /> �OS-7 5A 00 bio/9 <br /> OWNER/OPERATOR <br /> ` CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> LA CK 3JL <br /> SITE ADDRESS 3C1`I N Tri c 1 arc j-rGL G C15 3(.(�-} <br /> Street Number Direction Street Name CI ZI 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# 20 U— LAND USE APPLICATION# <br /> X201) $,j2— t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> tute6a CHECK if BILLING ADDRESS <br /> BUSINESS NAME ' <br /> J I PHONE# EXT' <br /> HOME or MAILING ADDRESS G FAX# <br /> F. D. i3' v 55125 (-4 ) 0 <br /> CITY GK n STATE Vl, ZIP C1 2 1 <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 SIGNATURE: NAWA <br /> DATE:�� (� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: LIS r 4£7- PAYMENT <br /> COMMENTS: <br /> JUN 14 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAI <br /> HEALTH DEPAR77V1ENT <br /> ACCEPTED BY: 1/ r�l .J EMPLOYEE#: C8 DATE: <br /> ASSIGNED TO: J2—L Virg EMPLOYEEM DATE: [ t) <br /> Date Service Completed (if already Completed): SERVICE CODE: f P E:Z3 pe <br /> Fee Amount: 4 SQ U Amount Paid _:3 y S — Payment Date (0 l v <br /> Payment Type L77r,nvoice# Check# g 3 Received By: {1/Z.r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />