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3AIV JUAt UIN 1LOUtN t Y EINVIRONP11MN 1'AL HEAL IH I)EPAKINIE1NT <br />• SERVICE REQUEST db <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # EXT, <br />( <br />SERVICE REQUEST # <br />FAx# <br />r - <br />U <br />C}WNER I OPERATOR <br />ASSIGNED TO: <br />LT CHECK 1f BILLINGADDRESS� <br />-e4t'A bEC 0 S/N C+ h y Ii V�S� /� ILL <br />+J I <br />FACILrrY NAME <br />Lo w E r`.O U f•t <br />Date Service Completed (if already completed): <br />SITE ADDRESS III 1 6,k—' E 1 T L t L Ar C- <br />rL C3 ' lam, i q $ Z t'i <br />Street Number Direction Street Name <br />Amount Paid <br />city Zie Code <br />HOME or MAILINGI�ADDRESS (if Different from Site Address) <br />Payment TypeInvoice <br /># <br />� � V � Q N A S.T <br />Ghec" r � J 2 <br />Received By: <br />U r, Street Number <br />Street Name <br />CITY1 L l <br />STATE <br />C- <br />ZIP ,�''^ <br />(9"S ✓ <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />3�9 <br />PHONE #2 EXT. <br />( } <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUES'TOR <br />REQUESTOii <br />CHECK if BILGING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT, <br />( <br />HOME or MAILING ADDRESS <br />FAx# <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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 aN that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TA andEE RAL laws. <br />APPLICANT'S SIGNATURE: ' DATE: © )} <br />PROPERTY/ BUSINESS OWNER OPERATOR I MANAGER tXJ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT is not the BILAINGPARTY, 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. �:� ,r, `", 'L_ -1 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: �,/�dyr dt'� ��% 6 i� <br />ate/ (�i/% AUG 11 2006 <br />r SAN JOAQUiN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EE #: <br />DATE: <br />ASSIGNED TO: <br />LEMPLLOOYYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: -0 <br />P I E: Z30 <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment TypeInvoice <br /># <br />Ghec" r � J 2 <br />Received By: <br />EHQ 48-02-025 SR ".(Golden—Rod) <br />REVISED 11/17/2003 <br />