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SAN JOAQUIN r7UNTY ENVIRONMENTAL HEALTH "EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE(REQUEST# <br /> UAJ <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FAcILnYNAME n C O Nt C <br /> SITE ADDRESS �t 1 D 1�°C. �u1 ac Ytt v✓ D>' T�-o- V 9 Y 3% <br /> Street Number Direction Street Name Cil ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> y Street Number Street Name <br /> CITY STATE ZIP <br /> YcM10 V632 - <br /> PHONE <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> (sl a) Q o — <br /> PHONE#2 ExT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORI/ CHECK If BILLING ADDRESS <br /> `` Y <br /> PHONE# Exr. <br /> BUSINESS NAME TYa- <br /> 7J n c 20 y - 127P-7- <br /> HOME Or MAILING ADDRESS II FAX# <br /> V Y JeA SCIS ( ) Z53 in 3cf- <br /> CITY '\ ya- STATE ZIP <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: IT_ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required rine <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. PAYM T <br /> TYPE OF SERVICE REQUESTED: RECE <br /> IVED <br /> COMMENTS: FEB 11 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Sr EMPLOYEEM �{-� DATE: 2 // <br /> ASSIGNED TO: EMPLOYEE#: - / DATE: / Cl <br /> Date Service Completed (if already completed): SERVICE CODE: P IE: 31 <br /> Fee Amount: (,� Amount Paid r (. .t Payment Date <br /> Payment Type Invoice# Check# Received By: ,'J <br /> EHD 48-02-025 .ARY=��3, 3ttld� <br /> REVISED 11/17/2003 <br />