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SAN JOAQUIN COUNTY ENVII NMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T C-9 <br /> of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A5 3tL-fi' 'dq S A-V &,;2,9#-3 <br /> OWNER/OPERATOR <br /> ' ha� d �� f CHECK If BILLING ADDRESS <br /> 11060-- <br /> FACILITY NAM O, � a 1 C�Ck� i Fpcd <br /> SITE ADDRESS � ) S j n � 1��/y� -a I ���/'A(`�+��/ J(I <br /> 14 a 43Street Number Direction eh '�� Street e Ci Mode <br /> HOME or MLING ADDRESS (If Different from Site Address) <br /> J <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �• ( I ��I/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME - i/ r �j PHONE# EXT. <br /> Y (a22) /- 37 <br /> HOME or MAILING ADDRESS p/ If! SAX# ,') 4& 6 34-2 <br /> CITY � M I V u- � STATE A�- <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 th' pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa ds, TATE and FEDERAL laws. Lf <br /> APPLICANT'S SIGNATURE: / DATE:ini - - I �� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN /IG( <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required VV 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: 131=QENED <br /> COMMENTS: APR - [ 20+1 <br /> SAN <br /> ENVIRONMENTAL <br /> H�I'H DEPARTMENT <br /> ACCEPTED BY: I—Otf c EMPLOYEE#: Qos� DATE: t <br /> ASSIGNED TO: 47— � EMPLOYEE#: �GGb kj DATE: J <br /> Date Service Completed (if already Completed): SERVICE CODE: /4?8 P/E:2- <br /> Fee Amount:0.'2 Amount Paid 3 b Payment Date S <br /> Payment Type Invoice# Check# d Rec iv By: l A- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />