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SAN JOAQOCOUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � ��Es _s�o053a � 5 <br /> OWNER/OPERATO � ( <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS (� LL1\ <br /> Street Number Direction "���� �treet�Na..- <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> \'•'�— Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCA ION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME p�C— PHONE# EX'' <br /> orM NG ADDRES FAX# <br /> CITY STATE(1 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,Standar s,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUI r DATE: 4/�\��� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT `� 1.../t� <br /> IfAPPLICANT 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 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: UST— PAY",ENT <br /> COMMENTS: I �e�..r — o�r�5oa..8s.'0 tp . i'-- ��x,� ik-+ter ef3 �-/u'�jj <br /> U JAN 3 1 2008 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPA TMENT <br /> ACCEPTED BY: rP� (_( V I, .A A EMPLOYEE M O Z DATE: / J9 0n <br /> ASSIGNED TO: S 4-c tG ' r ^c #:EMPLOYEE 14 <br /> r..7 DATE: 01/j ?1 <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: JC�`� P 1 E-.,1_3�jdY <br /> Fee Amount• " Amount Paid acl4, O /j Payment Date ( 31 I0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rq� <br /> REVISED 11/17/2003 <br />