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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus' ess or Pro city FACILITY ID# SERVICE REQUEST# <br /> q,5-? n4 qi) <br /> OWNERI&E CHECK if BILLING ADDRESS <br /> FACILITY NAME - <br /> SITE ADDRESS W j <br /> 0(/dU � � <br /> Street NIL/ Direction ee't Nama 1(11'-" "-& NY �Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> JZ <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) 47- aw_o <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) qg <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR •//, , CHECK if BILLING_AD <br /> BUSINESS NAME L//✓rl/1 PHONE# FXr• <br /> Aa i (moi <br /> HOME or MAILING kDRESS FAX# <br /> 2b 35 li�i /7 (9q) � (L✓T <br /> CITY / STATE 6 oc <br /> ZIP <br /> BILLING ACKNOWLEDG MENT: 1, 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,Standarn�,JS <br /> TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: j i 1IL4� DATE-:��� o-A Zz <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 enviromnental/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: a -C% E-r pi 7 d F I % R NT <br /> COMMENTS: DEC 0 6 2006 <br /> SAN JOAQUIN COUNTY <br /> EVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Q (_t t/e t EMPLOYEE#: 032-4 DATE: / 2- & 1, <br /> ASSIGNED TO: EMPLOYEE#: .2-�•70 DATE: 12-r (0 <br /> Date Service Completed (if already completed): SERVICE CODE: c1 <br /> Fee Amount: )�S. 61�0 I <br /> Amount Paid OS Payment Date !Z <br /> Payment Type Invoice Al Check# ` Received By: <br /> EHD 48-02-025 A - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />