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SAN JOAQUIN ONTY ENVIRONMENTAL HEALTH DE ,Tm GR I G I NL <br /> SERVICE kEQUEST <br /> Type of Business or Property , r FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Lb�{� eo c'--1,V z- S f�y'� (Tec CHECK If BILLING ADDRESS <br /> 1 <br /> FACILITY NAME cJT <br /> SITE ADDRESS 11 <br /> Street Number Direction St et Name Citv2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t-+AR,� "`FL� M A t <br /> l W 1V CHECK If BILLING ADDRESSEZ <br /> BUSINESS NAME , PHONE# EXT. <br /> S�evv K� 5���� sem.✓us . _T�: �6 ' �l <br /> HOME Or MAILINGA DRESS FAX# <br /> b�S Chu t,t(n U`e. (46) 4pn <br /> CITY LCL �Cc n STATE Ck ZIP q 57 11 <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 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. t .,,�/� <br /> :.�e <br /> APPLICANT'S SIGNATURE:'JR` -' CLL L.L- L • �'k���t%--+-t✓ DATE: i !O� W <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® \c�� &'L tau ( � <br /> IfAPPLICANT 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 t0 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: t yl S c*W t.1 ( -2 - Jn Cc �J �Y���G I�J T n <br /> COMMENTS: •i-li Z c✓t Cl�f'L\,e +&-LL ,Y1A.ill� 6 -Qfp(cftk `l <br /> IEck, AUG 18 2006 G►�s ',c c�1 <br /> SAN do/\QUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: (��� 4"l DATE: <br /> 1 1- i <br /> ASSIGNED TO: I g (4"/b, 64 <br /> EMPLOYEE#: y� / DATE: <br /> wA <br /> Date Service Completed (if already completed): SERVICE CODE: i C(Z PIE: GI <br /> Fee Amount: " Amount Paid Payment Date Fj <br /> Payment Type lj Invoice# Check# ZZ3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />