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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type Businessor ro erty FACILITY ID# SERVICE REQUEST# <br /> OWN /OPERATOR CHECKif BILLING ADDRESS <br /> FAciurY NAME V 0 <br /> SITE ADDRESS <br /> Street Number Direction �N Street Name Ci ' 7in Code <br /> HOME Or MAILING ADDRE (If Different from Site Address) <br /> 1WI lJ Street Number Street Name <br /> CITY STATE C' z <br /> PHONE#1 APN# LAND USE APPLICATION It <br /> P14ONNE�#•2 EM BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME P A/ EXT <br /> HOME or MAILING ADDRESS CN FAX Y <br /> (3 V /-L <br /> n <br /> CITY STATE <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, rMh <br /> and FEDERAL laN. <br /> APPLICANT'S SIGNATURE: /l• . IAII/[.ei1/ DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT-0 Y <br /> If APPLICANT is not the BILLING PARTY 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: RECE/ T <br /> COMMENTS: MAY 2 2 <br /> 2006 <br /> SAN JOAQUIN COUNTY <br /> HEALTH DEPAAL <br /> ENVIRONMENTRTMENT <br /> ACCEPTED BY: SRI 0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: al �v EMPLOYEE M 0753 DATE. S 22 G(ri <br /> Date Service Completed (if already completed): SERVICE CODE: 1 -71 PIE:2 D6 <br /> Fee Amount: 277 1 Amount Paid aq� , Payment Date 5 2 A <br /> Payment Type ✓ Invoice# Check# ` '�_ Received By: ��. .. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />