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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' ' OU It <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> r 0 <br /> FACILITY NAME <br /> SITE ADDRESS Z�I , E ''1 1:5)63 D� —5`�Q 0j`7 / Z� <br /> /Street Number Direction Street N �4 r la ' Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ) � �J <br /> Stn � 'e0.fc, SCQ.t rZ/ GZ I:R-'-'05S <br /> CITY , �;a c� <br /> PHONE#I Exr. APN# <br /> Exr IQqyI.NN CODE <br /> PHONE#2 C` <br /> ( ) I <br /> CONTRACTOR/ S� <br /> REQUESTOR C O Ttp GADORESS❑ <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS2 , O LA —(�.�_ssS Ctia CKD <br /> CITY0 71, - - Z- O <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: �fDATE: 1-2- -07 <br /> T <br /> PROPERTY/BUSINESS OWNER❑ OPERA II'OR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proofofaulhoriZalion to sign is require rJ 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 as it is available and at the same time it is <br /> provided to me or my representative. _ <br /> TYPE OF SERVICE REQUESTED: U r"F.,r{c 1 FA-£-E C C; <br /> COMMENTS: R�C <br /> MAR 12 2aal <br /> 14 G0014v( <br /> SAN��apptME T ENS <br /> nENTH OEpAR <br /> ACCEPTED BY: U L L �'�-- I rt EMPLOYEE#: DATE: f I l7. <br /> ASSIGNED TO: --T—AS6 yoOu�p S EMPLOYEE#: q.(I t f,S DATE: _'3 /`2- f7 7 <br /> Date Service Completed (if already completed): SERVICE CODE: j IS' <br /> Fee AmountPaid 1 , (Sb Payment Date �j 1'Z I p 13 <br /> Payment Type �z Invoice# Check# L.t bti Received By. <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />