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Dec.22 09 12:21p E1it-V Contactors 1209461042 p.4 0ra <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME- <br />I <br />FACILITY ID # <br />HOME Or MAILING ADDRESSFAX <br />1 <br />SERVICE REQUEST # <br />H <br />OWNER 1 OPERATOR <br />DEPS <br />N <br />I <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: VOA/ FL, u E- <br />SITE ADDRESS 2dbl <br />5 * <br />EJ— DI -11-A00 <br />l 6 <br />SERVICE CODE!LC I <br />�J ITIN �� <br />cbOlo <br />StreetNum6er <br />Direction <br />Street Name <br />Payment Type <br />citv <br />2i Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Received By: -� <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />EXT. <br />PHO E}� <br />APN # <br />LAND USE APPLICATION 4 <br />i <br />l.C� 3 — { <br />PHONE42 EXT. <br />BOS DISTRICT <br />LOCATIOt�CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK If BILLING ADDRESS <br />REQUESTOR ANY Lo Uv I <br />BUSINESS NAME- <br />I <br />PHONE /� EXT. <br />U <br />HOME Or MAILING ADDRESSFAX <br />1 <br /># <br />1 ) <br />CITY 5 V l STATE zip t <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, SMM7�� <br />APPLICANT'S SIGNATURE:DATE: Z/ZI <br />PROPERTY/BUSINESS OWNER❑ OPERATOR IMA\AGER❑ OTHER AUTuoRizEDAGETTN PUCCI 5UEMZ <br />IfAPPLiCAmT is not the BILLAxG PAR7t proof of authorization to sign is required i Titte <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�ame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />L. <br />(`( <br />�N <br />SOP ON EENT <br />SP <br />DEPS <br />N <br />ACCEPTED BY: D L -C Veit <br />EMPLOYEE #: -2-1 <br />DATE: 209 <br />ASSIGNED TO: VOA/ FL, u E- <br />EMPLOYEE 1 7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE!LC I <br />P I E: �3 U <br />Fee Amount: Tf�? <br />Amount Paid3 (f S DO <br />Payment Date <br />(�. 0 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: -� <br />EHD 48-02-025 . SR FORM (Golden Rod) <br />REVISED 1 111 712 003 <br />