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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> K o C 6-1/L C--F �dC'�' <br /> OWNER/ OPERATORCHECK if BILLING ADDRESSO <br /> �7 C _ <br /> V/112 4 / L C ,< - L s C o1/�L L t C-71--C� /Z / ECS. <br /> FACILITY NAME /-S L <br /> SITE ADDRESS l 3 S ! /t 777/,7 c Ll L� c-S'3 7C <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> C�-Z � L V t1, S f Street Number Street Name <br /> CITY STATE ZIP <br /> 0/1 9 3 7� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zy- ) ') 3 ,F— �' 7- " I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L CHECK If BILLING ADDRESS <br /> BUSINESS NAME V C PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> SfI—i�r � <br /> ky-r /4i7cic�� ( ) <br /> CITY STATE 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 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,Standards, STATE an FERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> /l <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 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: C U d�� f fir✓ /2Z�C// G J RECEIVED <br /> COMMENTS: JUN 16 <br /> 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: "">. - DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CO - P I E:�� <br /> Fee Amount: G Amount Paid Payment Payment Date O Jo <br /> Payment Type Invoice# Check# Zi-7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />