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SANJOAQUINCOUNTYENVIRONMENTALHEALTHDEPARUMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# l�SERVICE REQUEST# <br /> rA <br /> OWNER/ OPERATOR <br /> t,s5- n ryn®� /w'D <br /> FACILITY NAME CHECK if BILLING ADDRESS <br /> ���lC/` ,v <br /> S 1.t9 . 7f-2 Le.J <br /> SITEADDRESS ng� (� C�, V7fIle <br /> Street Number Direction C--r /a,v— Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#f EXT' APN# qB6S <br /> AND USE APPLICATION# <br /> PHONE#2 EXT. DISTRICT LOCATION CODE <br /> (40%-) 41d - 4�/ I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1/n CHECK If BILLING ADDRESSE] <br /> L r <br /> BUSINESS NAME PHONE# Ems' <br /> 47gpC a rn 37 <br /> HOME or MAI ADD S FAx <br /> o FTI I 9'N- // 7 <br /> CITY -(;4- TATE P <br /> E 26 3 <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[his application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,SZZZ��- <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OV NER y V OPERATO IANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY 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: L,Ir <br /> -�:T ' EN ( <br /> COMMENTS: C .rte •ee./L q/ SF/GL, y,r-�/may/r <br /> L--�'��T�r'�cJ -SF/6L, r-s��c-� , JUN 2 1 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 7 n <br /> Fee Amount: l3"n Amount Paid Payment Date 21;f I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />