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SAN JOAQUIN�.OUNTY ENVIRONMENTAL HEALTH is dPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�.t/✓.ove�A7io-.� <br />FACILITY ID # <br />� OO��j�� <br />SERVICE REQUEST # <br />S�.0o41�9�j- <br />OWNER/OPERATOR//) <br />/f <br />CHECK If BILLING ADORES5� <br />FACILITY NAME <br />AOu/ <br />G2.oD.e9�/a� <br />SITE ADDRESS <br />SEIGIOF�O <br />Number <br />I Dir`ection <br />f%d� .. <br />Street Name <br />�yc� <br />i <br />Xray <br />Zi Catle <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY (� iQ9mE <br />STATE ZIP <br />PHONE#I EXT. <br />(9/3 I J.// - 36 IT <br />APN# <br />LAND USE APPLICATION# <br />PHONE 92 Ex . <br />( ) <br />ASSIGNED TO: <br />BOB DISTRICT <br />LOCATION COLE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADORE <br />BUSINESS NAME <br />�E.ZI//LF <br />PHONE ExT) <br />.IOL`JJ/O�✓AL <br />�y✓pe/.,/�L/iJ <br />,�� <br />HOME or MAILING ADDRESS <br />FAx# <br />(J'" ) f ;I— <br />CITY <br />STATE <br />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 FE ERAL 1 ws. J/ / <br />APPLICANT'S SIGNATURE: C ���C DATrE�'r}� <br />PROPERTY / BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT {♦0 /a/J- /, L <br />I,ffAPPLICANT is not the BILLING PARTY proof of authorization to sign is required/ t 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: &-S 71 <br />pAYMEN7 <br />COMMENTS: <br />PEC' t -- <br />APR 5 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />DEPARTMENT <br />APPROVED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: —7 3 �/ / i <br />u V <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />P ( E: 2 Q <br />Fee Amount: <br />Amount Paid <br />"? -- <br />Payment Date — O�✓ <br />Payment Type ,/ <br />Invoice # <br />Check # <br />t..f, <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />0 <br />