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SAN JOAQC ' rOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;`— SERVICE REQUEST �- <br /> Type <br /> ��of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cbk)D�INl UM <br /> OWNER/OPERATOR Fb LT,� <br /> ll �� CHECK It BILLING ADDRESS <br /> FACILITY NAME AsiApcp� -PLP,--r— <br /> SITE ADDRESS <br /> --r—$READDRESS <br /> Stmt Number I Diniction I treat smacity 230 Code <br /> HOME <br /> EEJor MAILIPD AnnRESS (If Different from Site Address) � � L Pp S'-�' F— _ e— <br /> IOC���' Stmt Number Street N .. <br /> CITY �l->YAS1 A-t' TATjr� I!A ZIP <br /> PHONE#t EXT. APN# LAND La PPLICATIO ems, <br /> (925) 2`x`1 -321 (a "1_B _o y ,i - D <br /> PHONE#P EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR e 9cr �� tL_L <br /> F{�,« CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAx# <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prep Is app Ic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COuNT'Y Ordinance Codes,Shwnda ds, d FEDERAL laws. P <br /> APPLICANT'S SIGNATURE: � DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is of 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 JoAQutN 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: PAYMEN , <br /> F <br /> COMMENTS: <br /> s u L)b/ {'-•✓t I� o t• , :�") e .I 1, f 5 2006 <br /> l <br /> bo— cam.- <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 57,/// D <br /> ASSIGNED TO: V EMPLOYEE#: O 3 / DATE: S S 06 <br /> Date Service Comple d (If already completed): SERVICE CODE: P/'E: <br /> Fee Amount: C Amount Paid ` Payment Date S \5 I G6 <br /> Payment Type Invoice# Check# ?--I� Received By: (s <br /> EHD 4842-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />