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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ONlNER 1 OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 07 w -j <br /> W 148 � - E�e� A't 1t;.� I�o�o �, n� gsz�� <br /> 11611 01Street Number Direction treat Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ZZQ W MoInUNt LA j G 3-01 Tr B j CO <br /> Street Number Street Name <br /> CITY sC V� STATE CA ZIP d1 'C,20-7 <br /> PHONE#I 1 r+ �']� E'(T APN# LAND USE APPLICATION# <br /> (2404) V% 472:-7'700 -- 1 o %. 037 Pro - /0 -/5- <br /> 2-PHONE#Z EXT. BOS DISTRICT =ffCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR f - i x CHECK if BILLING ADDRESS <br /> BUSINESS NAME /��L�^ � PHONE�# Err. <br /> HOME or MAILING ADDRESS V. �.l x FAx# <br /> cam► ) 3r <br /> CITY , !, STATE ZIP 9 L y <br /> BILLING ACK i11iQWLED EMENT: 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 <br /> or 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: �l7 DATE: /0 r 19-/J <br /> PROPERTY/BUSINESS OWNER❑ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: <br /> COMMENTS: PAYMENT <br /> CO - -/U �� l�� �[ (� RECEIVED <br /> 0 (Wily% OCT 19 2010 <br /> SANC ROCOUNTY ENVIVIRONMNM ENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> 492 <br /> A$$IGNIED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: .� P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM( olden Rod) <br /> REVISED 11/1712003 <br />