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---`G�.s.• -A L'1\♦t1%,Vt I1r1L•1\1 HL 11L'H,L 11111 EFAtC 11NIEN T• <br /> SERVICE,REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO�R� <br /> CHECK if BILLING ADDRESS D <br /> _ FACILITY NAME <br /> SITE ADDRESS <br /> �r e er DL Street Name CI <br /> Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> StreetNumbe _ - _ Street Name <br /> CITY <br /> STATE ZIP <br /> PHONE#) EXT. <br /> APN# LAND USE APPLICATION# <br /> PHONE#T `'PT• BOS DISTRICT, LO�{4TJ�ODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUEST <br /> C <br /> • CHECK if BILLING ADDRESS O] <br /> BUSINESS NAME TIT <br /> P f Exr <br /> HOME Or MAILING ADDRESS l �� ` <br /> CITY STATE (C A ZIP <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 or <br /> 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 la S. <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR J MANAGER�. AUTHORIZED AGENT <br /> IPPAUCANT is not the BILLNGPA=proof of authorization to sign is require Tire <br /> -- ArtJTIiORIZATION 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: <br /> :. COMMEliTs. <br /> RECEIVED <br /> NOV 12 2009 <br /> SAN <br /> ENVIROTM <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEP Y: EMPLOYEEWCODE �� <br /> DATE:AssIGNED7OEMPLOYEEDATE:Date Service Completed (if already complet p <br /> Fee Amoun . GO Amount Paid <br /> Payment Date <br /> Payment Type l� Invoice# Check# l 1 <br /> E <br /> o Lo Z Received By. . <br /> EHD 48-02-025 k <br /> -REVISED 11/17/2003 5��7�d�[t'Rbd) ? <br /> by <br />