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Op <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> !21 GI�1-1 U1�; L i <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME <br /> SITE ADDRESS 1-70,:7- DA <br /> � <br /> Street Number Direction Street Name <br /> cmixzl eaae <br /> HOME or MAILING ADDRESS (if"Different from Site Address) <br /> ,,/ Street Number A Street Name q 7 2 <br /> CITY /wav STATE //1f . xIP /�Y✓ <br /> PHONEL#t ExT• APN# LAND USE APPLICATION# <br /> PHONE t12 Exr. BOS DISTRICT LOCATION CODE <br /> I ( I - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> jREQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> HOME or MAIuNG ADDRESS /fav FAX# 1 <br /> CITY I STATE ZIP J� <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAH JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST nd FEDERAL I <br /> APPLICANT'S SIGNATURE: DATE: J� <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/IVIANA ❑ OTHERAuTHORizEDAGENTI� - <br /> IfAPPLICANT is not the BILLING PARTY roof of authorization to sign is required 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: <br /> COMMENTS: y�y�A , lPAYMENT - <br /> Sf�A�iQGT �IJSU�Ij7G� ago J !/!/ RECEIVEIJ <br /> 2- 74 � ') ) JAN 18 2011 <br /> _ y'� c 3,0 �y� yj ti. / 1 SAN JOAQUIN COLIN'rY _ <br /> / ENVIRONMENTAL - <br /> rj HEALTH OFPARTMENT <br /> ACCEPTED BY: EMPLOYEE ' DATE:W A- 'IZZI201 <br /> ' <br /> ASSIGNED TO: EMPLOYEE#: t ♦ i DATE: <br /> _n <br /> Date Service Completed (if already completed): SERVICE CODE., P i E: /3 <br /> Fee Amount: 4 <br /> Amount Paid S" Payment Date f 8 L2"j 1 . <br /> Payment Type G Invoice# Check# 7 Received By: <br /> EHD 48-02-025 SR FORM(Go en Rad) <br /> REVISED 1111712003 <br />