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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME r <br /> SITE ADDRESS / i' I l/ C_ C_•ta k Ue <br /> street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> l ) Lk-099 5 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � (( CHECK If BILLING ADDRESS IT <br /> BUSINESS NAME PHONE# EXT. <br /> L.��z U cch�r C-� r5 .1—rlc: c.: 9 61- 6,3—3 <br /> HOME or MAILING ADDRESS FAx# <br /> Q W� r c ) ��/ (o3 a <br /> CITY L STATE CA- 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 and FEDERAL laws <br /> APPLICANT'S SIGNATURE:', & y1 4 —tt DATE: '7 a Y-oS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT PI &A uiGe- CO c-r a�t2a rU� <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. N� <br /> TYPE OF SERVICE REQUESTED: RECEIV E <br /> COMMENTS: <br /> JUL 2 4 ?_00 <br /> SAN JOAQUIN COUNT! <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: %% EMPLOYEE#: f>ell DATE: 7.. 2 yreg, <br /> ASSIGNED TO: EMPLOYEE M / DATE: ? � <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: /moi .t9 <br /> Fee Amount: .2-1� Amount Paid $ 1Z9 Lf. 0 D Payment Date "7 <br /> Payment Type ✓" Invoice# Check# 13 08' Received By: <br /> EHD 48-02-025 SRF (dolden Rod) <br /> REVISED 11/17/2003 <br />