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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL•TH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST.# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME A?7-S X04;77-( <br /> D4; J <br /> SI DR SS /\ ,' F61_'qe'119 <br /> G�- <br /> Street Number Direction ...3 w f 4 lt,.�e_tr�e ;ity ! e <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE .Zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS Er <br /> BUSINESS NAME PHONE# ExT. <br /> B <br /> HOME or MAILIN DDR FAX# <br /> Ille2Q ( 11 <br /> CITYSTATE zip y <br /> '�'/oew_'�n 4 e A!�� -?x I <br /> BILLING ACKNOWLEDGE ENT: 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 FFIDE&AL laws. <br /> APPLICANT'S SIGNATURE: DATE: w <br /> PROPERTY/BUSIN FSS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHoRIzED AGENT❑ <br /> If APPLIcAw is not the BILLING P_ARTS,`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. ?_0&L xAl— AE'I,q-149— �� Dd At <br /> TYPE OF SERVICE REQUESTED: v&ri + AA 1102z> PAYMENT <br /> COMMENTS: RECEIVED <br /> JUN 17 2010 <br /> 00 <br /> SAN JOAQUIN COUNTY N07 01$0A9D <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: (e)_1 3 DATE: 6�1 to <br /> ASSIGNED TO: vreAnq <br /> EMPLOYEE#: (0243 DATE: la J7 )D <br /> Date Service Completed (if already completed): SE"RVICECODE' 6�,� PIE: 3(,Q?j <br /> Fee Amount: �� [31� Amount Paid ?�O Payment Date {o { It 10 <br /> Payment Type ,r- invoice# Check# s 2 S Received By: — <br /> EHD 48-02-025 SR FORM(Gotden Rod) <br /> REVISED 11/17/2003 <br />