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SAN JOAQU ;OUNTY ENVIRONMENTAL HEALTI APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR LQv�(� � _ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �� 1� w� <br /> �� � Street Number DirectionP Street Name Cit Zi Code <br /> HOME orMAILINGADDRESS (If Differe rom Site Address,) }^} <br /> IG l �-�/'`�St'edt Number Street Name <br /> CITYO, , -l1`,I ^ y $TATEo ZIP 3 1 n I <br /> PHONE#1 IL TEXT. <br /> APN# LAND USE APPLICATION# <br /> (L) jZ -Lgwg3 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> (?CC) S `OO <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 0 PVA fa% CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� C7 !n, }�y� 0 E# _ t Exr. <br /> HOME or MAILING ADDRESS FFAAX# Q p� <br /> PC). <br /> CITY �—o ' Cd STATE Q)12) 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,Standard , STA D L wS. <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER El PERAT ANAGER ❑ OTHER AUTHORIZED AGENT� I� <br /> If APPLICANT is of t BILLING PARTY,proof of authorization to sign is required 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 a� it is available and at the same time it is <br /> provided to me or my representative. 4 Y <br /> TYPE OF SERVICE REQUESTED: in <br /> COMMENTS: V <br /> S N�AQv'N 014U V 0 7 2007 <br /> HFACTjtOpq,Z,V LAMENT HEALTH <br /> WRM1T/SERVICES <br /> ACCEPTED BY: EMPLOYEE#: tA <br /> ASSIGNED TO: AIM-2 U EMPLOYEE#: 2.1272 Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: d Amount Paid a }� Paymefnt Date 1/0 1 <br /> Payment Type Invoice# Check# , C l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />