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SAN JOAQIWOUNTY ENVIRONMENTAL HEALT(WPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEEST# <br /> /Z�< 6 <br /> OWNER/OPERATOR r CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESSl�/�CJ2o rF y�Qm� ve ��� �, us to <br /> Street Number Direction Str et Name C 2ID Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> OM) - 7 22 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /, / /� A � CHECK if BILLING ADDRESS® <br /> PHON Exr. <br /> BUSINESS NAME Ame6_ `n —"7660 <br /> � FAx# <br /> HOME or MAILING ADDRESS l� sT^p) � <br /> CITY / STATE ZIP qS�W'5 <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 STATEd F ERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: ��,210/OGY <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 /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: OC <br /> COMMENTS: JUN 2 C 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: j <br /> ASSIGNED TO: EMPLOYEE#: p DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P E: <br /> Fee Amount: ( Amount Paid `$ 3m 5 D l� Payment Date <br /> Payment Type . Invoice# Check# �`� Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />