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SAN JOAQU•COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />F/+omN <br />SERVICE REQUEST # <br />SP -0053a I <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �, I � _ �u� C I [ ' s- <br />`L <br />PHONE # EXT. <br />SITEADDRESS r1(„�3V�LL, A <br />J <br />Street Number <br />F <br />Direction <br />(A A41 <br />r ""'-' <br />Street Name <br />�� C ` <br />4 5 36� <br />1 Sr Cotle <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Ex . <br />( 1 <br />APN # <br />ACCEPTED BY: <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />ASSIGNED TO: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO-RC <br />' D � '� <br />� f <br />IAT�I�-1 rl,Gl,4 !2 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING A DRESS <br />4�7 Gor,`cc <br />FAx <br />9, 3�6-�5�13 <br />CITY Lalu <br />STATE eA 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 <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that 1 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: <br />PROPERTY/BUSINESS OWNER ❑' OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN'rle 4�4&!/r�C rQ± <br />IfAPPLK'AM' is not the BILLING PAR7Y proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: <br />' D � '� <br />COMMENTS: <br />JAN 2 5 2008 <br />JAN 2 5 2008 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL ENVIRONN <br />NT HEALTH <br />HEALTH DEPARTMENT <br />PERK I/SL'RVICES <br />ACCEPTED BY: <br />EMPLOYEE #: CO <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#:mimlapda /'1 <br />V <br />DATE: <br />Date Service Completed (if alredy completed): <br />SERVICE CODE: <br />PIE: f7 <br />o <br />Fee Amount: I (� <br />Amount Paid <br />azc/ f <br />Payment Date <br />'1;-51D <br />Payment Type <br />Invoice # <br />Check # / r7 1 <br />Received By: Lit) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 n 1 <br />