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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILrrY ID# SERVICE REQUEST# <br /> ReI:i i3O'"7410,'/' �" Ll" <br /> OWNER OP RATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction ' Street Name C' Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PNONE#tExr' AP/hN� # LAND USE APPLICATION# <br /> PHDNEtitT 9�zd z Grbtyf�r Lj BQS DISTRICT L� LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Exi <br /> BUSINESS NAME / O P� <br /> HOME or MAILING ADDRESSFAX# <br /> 2 Z [ A/ 0a-k �+. • Y,L' B - �. T� <br /> V";- ) <br /> CITY L,e 1 STATE G ZIP q 5-2q 0 <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 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 SIGNA'T'URE:K—�[�� DATE: / e <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORtZED AGENT❑ <br /> If APPUCdNT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA'T'ION: 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. 1� <br /> TYPE OF SERVICE REQUESTED: R �CJ -O u/f'ct fl%!!, /✓ tV� �� I V 1 <br /> c <br /> COMMENTS: 6 j /c)c <br /> ICY JUN 2 12006 <br /> OP,QllIPi COUt!TY <br /> �� jrc .� '••yt7'i'rr�ie-mL �-'ti- l"�r'� VIRONMENTAL <br /> IGXC'C.rSY EALTH DEPARTMENT <br /> ACCEPTED BY: C'Lt o E I ., EMPLOYEE#: 1)3--�!-( DATE: 6 <br /> ASSIGNED TO: ML D, NA EMPLOYEE#: .45'3 � & DATE: Z.[ <br /> Date Service Completed (if already completed): SERVICECooE: PIE: Z_(v. p <br /> Fee Amount: (Q(� •trU <br /> Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />