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Odt 09 -06 09: 55a H R En9eer i ng 81884237E P. 2 <br /> SAN JOAQUIN COUNTY EN'IRONNIENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# . SERVICE REQUE T <br /> �s STP:, I tot 1 �A <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> L Q0 klell <br /> FACILITY NAME <br /> SITE ADDRESS �(� �AG y\j ItA <br /> TI <br /> Street Number Direction <br /> Street Name Cit Cotle <br /> HOME Or MAILING ADDRESS (It Different from Site Address) (p 11115?� <br /> Street Number Slree Name <br /> r-± <br /> CITY S7,P.1E ZIp <br /> \ 1 ley <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (5IP9) 5�3- $235 223 - o-1l- DI <br /> PHONE#2 Esr. BOS DISTRICT LOCATION CODE <br /> 15 l 3�2 - '1 'IS <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> "REQUESTOR CHHECK If BILLINGADDRESS,�I /.� QTAXA <br /> Gr ,Ir $�� t/n� � • evt� ✓ l: V L <br /> STATE l/'AJ Zip ✓�i�f- <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 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. 0-1% �y, <br /> APPLICANT'S SIGNATURE:{`._-7Pw.._'`�'��4� DATEE:t t—r ` \ � �0� <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER ❑ OTD R AuTIIORIZED AGENT pJ (!!I2yA 'Vzcg;.t <br /> IfAPPLICANT is not the B)LUNG PARTP 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 enviro mental/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: 1Z,5 <br /> COMNENTS: NOV 0 7 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: .�yf <br /> ASsIGNEDTO: y EMPLOYEE b DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Pf E: <br /> Fee Amount: . -70Amount Paid 57p p (� Payment Da Z O <br /> Payment Type Invoice# Check# � Received By. <br /> EHD 48-02-025 SR'PORM'(Golddr) Do) <br /> REVISED 11/17/2003 <br /> 2 <br />