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SAN JOAQ COUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> '-12 E. A,I L E LL1 `f C (� c 7 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> F— I S I l tZo C. E V PtA C° - <br /> FACILITY NAME <br /> SITE ADDRESS A,k M -1--_ L 1 <br /> 6L13 I- Street Number i gimt Name cily gig Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / <br /> ?y-Street Number Street Name <br /> CITY C ^ µrQ STATE C ZIP cls /C <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION ODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> ( C WA-(,T-i44CHECK If BILLING ADDRESS <br /> BUSINESS NAME `� ` c �. PHONE# ExT. <br /> t6 <br /> HOME or MAILING ADDRESS FAX# <br /> 0to (014 )34-3 2- <br /> CITY <br /> CITY STATE 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 <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 applicati n and that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STA d F E laws. . <br /> APPLICANT'S SIGNATURE: DATE: —Z Z ® 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR%/MANAGER ❑ OTHER AUTHORIZED AGENT In r �- <br /> IfAPPLICf1NT 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. L,C.ST 4�,, F C7- T <br /> TYPE OF SERVICE REQUESTED: C V l 6,vi P r,.t R ECEI E <br /> COMMENTS: <br /> F03 2 4 2009 <br /> SAN JOACIUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: LVA <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: C / T— EMPLOYEE#: / 2 -2 DATE: Z-- - t <br /> Date Service Completed (if already completed): SERVICE CODE: !Ci PIE: <br /> G <br /> Fee Amount: . Amount Paid '1 Payment Date <br /> X15 Z <br /> Payment Type , invoice# Check# f, I b !S S L4 Received By: >� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />