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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTAPARTMEN <br /> T <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &ASTUYS 2-1 14 <br /> OWNER OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS i Lf 2--7A iir )ac LoAZ11)l <br /> Street Number irectlon t e C <br /> we <br /> HOME Or MAILING ADDRESS {If Different from Site Address} <br /> Street Number 3byet Name <br /> CITY STATE zip <br /> PHONE#1 Exr. APN 0 ( b LAND USE APPLICATION <br /> PHONE#2 Exr• BOS DISTRICT LOCATt I <br /> CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME. PHO #. Exr. <br /> iia- s <br /> HOME or MAILING ADDRESS <br /> GrrY — , STATE <br /> 11 zip r? <br /> BILLING ACK1V0_ WLEDGEMENT: 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, STAIE and FED RAL laws. c� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER LJ OTHER AUTHORIZED ACEN7 a <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title s <br /> AUTHORIZATION IQ RELEASE:INFO MATION: 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: / �--( 1 REcE1VED <br /> COMMENTS: <br /> FEB 8 2008 <br /> SAN JOAQUIN COUNTY <br /> 10EN_TH DEPARTMENT <br /> ACCEPTED BY: 0 EMPLOYEE#: DATE: 2_ <br /> ASSIGNED TO: 1 /u EMPLOYEE M �i3 1 a-7 DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: if p' P I E: <br /> I O 3© <br /> Fee Amount: Cf c ,�, Amount Paid � �ql GoPayment Date 2 <br /> Payment Type Invoice# <br /> 'FrFte'Cck# � � Received By. <br /> EHD 48-02-025 �r©�`� SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />