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SAN JOAQUIN-COUNTY ENVIRONMENTAL HEALTP DEPARTMENT <br /> a.. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> OWNER/OPERATO <br /> K # / CHECK If BILLING ADDRESS <br /> FACILTY NAME t <br /> r <br /> SITE ADDRESS <br /> StWreN'7fN�umber Direction w��~� treet Name ✓"^ ' " 'CI zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �y q <br /> zip <br /> &kx erg I• ( STATE 7 330 / —0Ir <br /> PHONE#1 E APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n p CHECK If BILLING ADDRESSW <br /> BUSINESS NAME Y//�(•/ — .� PH NE# EZT, <br /> u r e C fo-rs .� IC, �!o/ - (033 <br /> HOME or MAILING ADDRESS iFAx# <br /> A53,5 W t ) /- ( 3 <br /> CITY 5,�,oc�'. , " STATE !7 h zip L?iz[— ' OC <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�ITATE and FEDERAL laws. r� <br /> APPLICANT'S SIGNATURE: Jy�� �Yf �L� DATE:: /,I // //�,7C'//_ <br /> PROPERTY/BUSINESS OWNER 11OPERATOR/MANAGER 13IZ <br /> OTHER AUTHORED AGENT JOI oS•at'U[o,e C.A*-rd <br /> IfAPPLicAwris not the BiLLiNGPAkTY 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. <br /> TYPE OF SERVICE REQUESTED: RECEIVEn <br /> COMMENTS: DEC 11 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONHEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: Wp DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Paymen Date <br /> Payment Type III, Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />