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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />RECEIVED <br />PHONE# Ecr. <br />2 YD <br />00 6901-s-8 <br />HOME or MAILING/ADDRESS <br />JUN 17 2010 <br />FA%q# <br />/I/�J' <br />��r <br />COUNTY <br />O NERItOPERATOR <br />CITY /'� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />_ <br />(L P <br />DATE: r.,/// '7�6D <br />SITE ADDRESS/Cid' [~i <br />EMPLOYEE #: 6-z-(3 <br />DATE: !_ 1 d irp <br />Date Service Completed (if already completed): <br />b i StreXet Number Direction <br />SERVICE CODE: 5--,2- <br />S[reet N e <br />Fee Amount:23 D d?� <br />Amount Paid U� <br />Payment Date -� -0 Payment <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />Check # <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 1 <br />('ob- Z9d -[s <br />PHONE #2 EXT. <br />BOS DISTRICT <br />2 <br />LOCATION CODE <br />P <br />c ) <br />CONTRACTOR/ SERVICE REQUESTOR <br />REOUESTOR hme!/Slv <br />CHECK If BILLING ADDRESS <br />09 C>f-J 42J t f c(f- <br />COMMENTS: <br />BUSINESS NAME <br />RECEIVED <br />PHONE# Ecr. <br />HOME or MAILING/ADDRESS <br />JUN 17 2010 <br />FA%q# <br />/I/�J' <br />��r <br />COUNTY <br />(/fid) <br />CITY /'� <br />STATE zip 5P r-7/— <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 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 tins 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 law <br />APPLICANT'S SIGNATURE: ;ar/ DATE: C <br />PROPERTY / BUSINESS OWNER 11 OPERATOR / MANAGER 9 OTHER AUTHORIZED AGENT <br />If APPLICANT 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. <br />TYPE OF SERVICE REQUESTED: -!OO 1 -fli} <br />09 C>f-J 42J t f c(f- <br />COMMENTS: <br />RECEIVED <br />DONOTDISP <br />JUN 17 2010 <br />/I/�J' <br />��r <br />COUNTY <br />W <br />TMT <br />ACCEPTEDBY: 6[_ <br />EMPLOYEE#: e32_f <br />DATE: r.,/// '7�6D <br />ASSIGNED TO: ,/ 2 <br />EMPLOYEE #: 6-z-(3 <br />DATE: !_ 1 d irp <br />Date Service Completed (if already completed): <br />SERVICE CODE: 5--,2- <br />1 PIE: & Z <br />Fee Amount:23 D d?� <br />Amount Paid U� <br />Payment Date -� -0 Payment <br />Payment Type L/ <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />