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SAN JOAQUIP,,,.,:)UNTY ENVIRONMENTAL HEALTH 'ARTMENT <br /> M <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (-I,,-> �)[7� ::: I lz <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS a� (JJl� rva. <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Sbea[Number Street Name <br /> CITY STATE ZIP <br /> T-- -APN-# - ----- - - LAND USE APPLICATION# <br /> - - - ---------- ---- - -- <br /> (�` )4(vI- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAMEPHONE# E ' <br /> f .A n�S 'L S 7/13 <br /> HOME or MAILING ADDRESS FAX# <br /> h oho - U 13 <br /> CITYSTATE ZIP ). ;, <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 <br /> or 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. <br /> APPLICANT'S SIGNATURE: 4&J Q ly � 4-�LAg�ATE: J//D/D(o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT C7 lL}yn`.[},tom[_-P Yy r <br /> JJAPPLICANT is not the BILLING PARTT proof of authorization to sign is required I 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: <br /> COMMENTS: RECEIV E� <br /> F Eg � g 2006 <br /> SAN JOA pNMEN AL <br /> ACCEPTED BY: EMPLOYEE#: 2 DATE: BQVC <br /> ASSIGNED TO: t EMPLOYEE#: 7 a Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r O P/E: z3o� <br /> Fee Amount: Z Amount Paid *x-717 0 Payment Date O 6 <br /> Payment Type ✓ Invoice# Check# 11 1qg7 Received By: <br /> \EHD 48-02-025 SR FORM(Golden Rod) <br /> �FVISED 11/17/2003 <br />