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SAN JOAQUI1' (70UNTY ENVIRONMENTAL HEALT" DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />07 3 <br />SERVICE REQUEST # <br />S' 12--CD51), (3P <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />--reTWN 4 coviLl-rey PAP-1. E0A/.00 <br />SITE ADDRESS .2_330 <br />Street Number Direction <br />oi' <br />City Zip Code Street Name <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />eo <br /> <br />2- 9- vci 7 -0 / <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRIC - LOCATION. CODE <br />ONTRACTOR / SERVICE REQUEST OR <br />REQUESTORI ,..,} /A...a CHECK if BILLING ADDRESS <br />BUSINESS NAME FAR-X-60t4 950L-S P HONE # <br />01 ) 53c-1- --3`.1-2- <br />EXT. <br />HOME or MAILING ADDRESS <br />..,376) IA .A.c1C.110 Cir <br />FAX # <br />( ) <br />CITY /......co t STATE cit ZIP 61r6V,--'10 <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 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 FE L h s <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT- <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 />rovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: i-t 6-4-4- 77-/ -___.-,/,--ee, 0 6_4._ A.._.)4-Ai C-Ict E PAYMENT <br />COMMENTS: RECEIVED <br />MAY - 6 2009 <br />SAN JOAQUIN COUN <br />ENVIRONMENTAL <br />HEALTH DEPARTMEr <br />ACCEPTED BY: OL i VE-t. W.-A EMPLOYEE #: 0 szi DATE: 5 itilo f <br />ASSIGNED TO: C-4-,---71e-XE—C: c 0 EMPLOYEE #: 0 46, 7 DATE: 51(0(0 9 <br />Date Service Completed (if already completed): SERVICE CODE: 52:2_ <br /> <br />PIE: 3 0 2_ &, <br />Fee Amount: -It .2_1 0 . Amount Paid 4 c?.i 0 . 6-0 Payment Date 5-16m ei <br />Payment Type / Invoice # Check # 40 0 f Received By: <br />DATE: 5-4477 <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003