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SAN JOAQ U1P NTY ENVIRONMENTAL HEALTH PPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # 3 �Ob <br />SERVICE REQUEST # <br />P rL C6 <br />PHONE # <br />ZG� <br />EXT. <br />b S - I & <br />HOME or MAILING ADDRESS <br />O�s��{�� <br />OWNER/ OPERATOR <br />/U Liz* Lt" S'e' 37- 3 J� <br />EL L <br />(ZG"i) <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />C 0 <br />STATE CO— <br />ZIP gSZ.6i 6 <br />SITE ADDRESS <br />4 <br />r� � z <br />IeK ZLf- <br />W Street Number <br />9iYection <br />Street Name <br />� <br />✓ Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />EMPLOYEE #: <br />e,31-7 <br />3 t <br />DATE: '! 'j4 Qc' <br />Street Number <br />Street Name <br />CITY <br />P / E: d 6 <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />Amount Paid <br />APN# <br />--c 5- <br />L 3 S- 1(d -15- <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />2—e) --o 9 <br />BOS DISTRICT <br />LOCA ION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTO <br />( <br />CHECK If BILLING ADDRESS <br />BUSINESSAME <br />a)� t kD <br />COMMENTS: <br />PHONE # <br />ZG� <br />EXT. <br />b S - I & <br />HOME or MAILING ADDRESS <br />FAX # <br />/U Liz* Lt" S'e' 37- 3 J� <br />(ZG"i) <br />3 (o J'__ r 13 <br />CITY / _x <br />STATE CO— <br />ZIP gSZ.6i 6 <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 Di:PAwrmi.:N'r hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 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 rY Ordinance Codes, Standards, S'I'A'rE and FGDE'RAL, laws. <br />APPLICANT'S SIGNATURE: DATE:�K�U l <br />PROPERTY /BOSINESSOWN ER❑ OPERATOR/MANAGER ❑ OTHER AirniowzFi)AGENT <br />❑ <br />11'.9PPLICANT is not the BILLING P,tnTY, proof of authorization to sign is required Tule <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 enviromnental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMF,NT'AI, HEALTH H DEPART'MENI' 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:?7 <br />MENT <br />COMMENTS: <br />p <br />REC <br />SEP 2 g 2009 <br />SANet4NA 0 ME�{MENT <br />DEFAA <br />HE0TM <br />ACCEPTED BY: 0L <br />r `u C Q� <br />, ` <br />EMPLOYEE #: <br />� <br />DATE: A Z tl <br />ASSIGNED TO: cl E" <br />EMPLOYEE #: <br />e,31-7 <br />3 t <br />DATE: '! 'j4 Qc' <br />Date Service Completed (if already completed): <br />SERVICE CODE: CCl (1 <br />P / E: d 6 <br />Fee Amount: <br />3 q-5-0-0 <br />Amount Paid <br />y s ._ <br />Payment Date <br />2—e) --o 9 <br />Payment Type ✓ <br />Invoice # <br />Check # <br />`L� S b <br />Received By: NTJ— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />