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SAN JOAQUIN CO"NTY ENVIRONMENTAL HEALTH DEP'RTMENT <br /> �- SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> S Kr�sk: <br /> FACILITY NAME / <br /> SITEADDRESS <br /> Street Number Direction <br /> ll street---- <br /> HOME <br /> treetNameHOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> STATE Zip <br /> CITY <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> PHONE# Ev' <br /> BUSINESS NAME L r'�L <br /> L- n1S <br /> HOME or MAILING ADDRESS FAX# <br /> 6 14 6`R') - u13 <br /> CITY STATE e,n ZIP I <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: / e c �{:i�./�� ��ATE: �/a�O Lo <br /> T� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT G7 l O`,LinC.-PGr' <br /> IJAPPLICANT is not the BfLLtNG PARTY proof of authorization to sign is required <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: Cat AIMAZL— 44L JE�- _Oxrk <br /> COMMENTS: REC VED <br /> FEB 0 3 2006 <br /> UiN GOU <br /> ACCEPTED BY: EMPLOYEE#: ! DATE: DEpARTM T <br /> ASSIGNED TO: EMPLOYEE#: 03 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 7, U <br /> Fee Amount: - Amount Paid Payment Date 3 1) <br /> Payment Type Invoice# Check# � ) 93 Received By: �—. <br /> THD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />