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SAN JOAQUIN-COUNTY ENVIRONMENTAL HEALTF DEPARTMENT <br /> SERVICE REQUEST `- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> She o0 4 4 ! 03 <br /> 16(44- i`S/DENT/ L <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESS❑ <br /> TLGto GGESE <br /> FACILITY NAME <br /> SITE ADDRESS �/ K o�/E�- 7ZD . Ac Am Po 9sa�[7 <br /> 3 Street Number Direction Street Name Ci Zi Code <br /> HOME Of MAILING ADDRESS (If Different from Site Addre <br /> P. ©, Street Number Street Name <br /> CITY STATE tom` ZIP n I <br /> PHONE#t EXT. APN# ND USE APPLICATION# <br /> �i3► ) 6 - 4o4 1)49 - o - 2z - o <br /> PHONE#2 EXT. BOS ISTRICT LOCATION CODE <br /> CONTRACTOR VICE RE ESTOR <br /> REQUESTOR Jo/v CHECK If BILLING ADDRESS <br /> PHONE# ExT. <br /> BUSINESS NAME nOJES t4E G—/JO A L, -r//V <br /> AIS <br /> V . I / ) O <br /> HOME or MAILING ADDRESS 5 4C FAX# <br /> CITY L O C STATE /T/I ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 ap cation and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandarMd1TandF. L laws. q <br /> APPLICANT'S SIGNATURE: DATE: / ' 02 7 • �5 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTW <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. <br /> TYPE OF SERVICE REQUESTED: So/L fa l rA31 t try SruD - E <br /> COMMENTS: PAYMEN <br /> RECEIVED <br /> 7 2005 <br /> J < •-c.a. 'r�� SAN JOAQUIN COUNTY <br /> MENTAL <br /> ACCEPTED BY: Q(._i UE t EMPLOYEE#: ,rri 3 Z DATEa{ 7 e -- <br /> ASSIGNEOTO: H L46C. '-C EMPLOYEE#: C]F t/ DATE: (1-2-7(0 <br /> Date Service Completed (if already completed): SERVICE CODE: S'2 9 2, 2-- P I E: zC-e <br /> Fee Amount: (JtG 2 372 Amount Paid Payment Date <br /> Check# Received By: <br /> Payment Type Invoice# <br />