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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ; FACILITY ID If SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> \1% ['✓✓A CHECX it BILLING ADDRE55O <br /> FACILITY NAME L'. �- ��v' lJ s ,-*e•'Y <br /> SITE ADDRESS �-i���./ �-GE islr-'c� qs'Z 7, <br /> It, r-- Street Number pirectian Street Name City zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> I i', I W, Tatdd.e—r tZ,Y Street Number street Name <br /> CITY G t STATE ZtP <br /> PHONE#1 Ev. APN# LAND UsE APPLICATION# <br /> ( 70/f 003—/7J -/U <br /> PHONE#2 EXT, BIDS DISTRICT LC SON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# E.'. <br /> HOME or MAILING ADDRESS FAx# <br /> r ( ) <br /> CITY STATE ZIP <br /> BILI.iNG ACKNOWLEDGEAIENT: I, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identifies on this form. <br /> I also certify that t have prepared this application that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> tCOUNOrdinance Codes',Standards,STATE F'RAI.laws. <br /> TY <br /> APPLICANT'S SIGNATURE: DATE: 1114'/ 7 <br /> PROPERTY/BUsusEss OWNE11,4, /F,1ERAT0R/1N1ANAGER ❑ OTHE.R AUTHORizvo AGENTIfAPPLICAN7'isnotLLING'PANTY proof of authorization to sigh is reg1tired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirornnental/site assessment <br /> information to the SAN JOAQtnN COUNTY ENVIRONMENTAL.14FALTH DEPARTNIEN'r as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> Y. TYPE OF SERVICE REQUESTED: - I <br /> COMMENTS: <br /> 7 NOV 1 6 2007 <br /> ONtMEWAL <br /> jDA <br /> AI_iH OEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#:ASSIGNED TO: EMPLOYEE#:Date Service Completed (If already Completed): SERVICE CODE: —Z- PIE: <br /> Fee Amount: Amount Paid -'A? C�.f-) O Payment Date E( - <br /> Payment Type Invoice# (p `� - Check# i Received By: <br /> t <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ._•• - <br />