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SAN JOAQUIN 7OUNTY ENVIRONMENTAL HEALTH T)EPARTMENT <br /> s 1 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OcIn 'S� 1 3l� 5jWq5Wq <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> r 0 li <br /> FACILITY NAME <br /> SITE ADDRESS \n) <br /> LLStreet Number Tl' .",ion IS/-500 Street Na <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION# <br /> ( q ) - 33 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( I <br /> /* CHECK if BILLING ADDRESS <br /> BUSINESS NAME < �LeS SHONE# ' EXT. <br /> lylla <br /> HOME or MAILING ADDRESS �a FAX# <br /> le-I'D16 3ff lvi"q Ala M qo P- �2,4- 9 <br /> CITY4o /,( L„_, n STATE ZIP <br /> BILLING ACKNOWLEtD/1GIETMJ/EINT: 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 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 applica ' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA d FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: ( DATE: /�� U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT (� v(// / <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 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. ip <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: FEB 1 3 2006 <br /> SAN 1/0AQENV/RoU/IV C U <br /> OU <br /> HST y O PAR MINT l' <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: Z DATE: 7 G y <br /> ASSIGNED TO: p �/�`j EMPLOYEE#: fL DATE: �``7-3 Cb <br /> r •bzJ ��wvv <br /> Date Service Completed (if already completed): SERVICE CODE: t�� P/E. a 3© <br /> Fee Amount*.47.Z V00 Amount Paid � l ck Payment Date � �3 bb <br /> Payment Type Invoice# Check# `� S Z Received By: N G <br />