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JAN JVAQUIN II-OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ' Type of Business or Property FACILITY ID# W0-47276e) <br /> ERVICE REQUEST# <br /> 00 l 2- -7 1 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> F O�L�t-lY� <br /> FACILITY NAME <br /> S <br /> SITE ADDRESS <br /> Sheat Numtxr DIwtIon / it ame city ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> � r <br /> BUSINESS NAME `n PHONE# Eur. <br /> HOME or MAILING ADDRESS FAX# <br /> vv- ) CS <br /> CITY -� STATE ZIP Ila <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: 41e AL, DATES: w 13/us <br /> PROPERTY/BUSDHESs OWNER❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT LT/ <br /> If APPLICANT is not the BILLINGPARTY proof of authorization to sign is required Tirte <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. 2AY(/(ENT <br /> TYPE OF SERVICE REQUESTED: S 117 i RE <br /> COMMENTS 2005 <br /> 7i � <br /> e JUN 14 <br /> SAN JOAOUIN COUNTY <br /> S � ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Q r!A/` �1EMPLOYEE#: 31-1 DATE: <br /> ASSIGNED TO: 1 ` V✓S*G VG5C5 EMPLOYEE#: -7 DATE: <br /> 3 1 <br /> Date Service Completed (if already completed): SERVICE CODE: ' Q P 1 E: 23 t)la <br /> Fee Amount: 2 6(] Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 45-02-025 SR FORM(Golden RO�)1 <br /> REVISED II/17/2003 Vyl-- <br />