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SAN JOAQUIN COUNTY ENVIOWMFkAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> SERVICE REQUEST# <br /> Type of Business or Property FACILITY ID# <br /> S12 q <br /> OWNER/OPERATOR �-) � � `� CHECK if BILLING ADOREss❑ <br /> FACILITY NAME lw*? � <br /> IAC" ' T- -1 <br /> SITE ADDRESS I O 1 vl q �� ♦< �i'tJ '�-rT N Da_ <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address <br /> 10 O 1 W �� Street Number Streel Name <br /> � <br /> CITY STATE r. <br /> L/I1 ZIP iT <br /> PHONE#1 E> . APN# LAND USE APPLICATION# <br /> 0 - 01 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) CGJ((�� n( <br /> CONTRACTOR/ SERVICE REQUESTOR v � <br /> REQUESTOR f � k CHECK If BILLING ADDRESJQl <br /> BUSINESS NAME I (v PHONE# ' <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 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. 1, <br /> APPLICANT'S SIGNATURE: L _�� � DATE: (DAP o X 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERAOR/MANAGERR OTHER AUTHORIZED AGENT❑ (y 4-- 1� <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titte�— <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. C <br /> TYPE OF SERVICE REQUESTED: JS S ��!L. S Lt t7-,q B IL t S J-'t'0 Y Y <br /> COMMENTS: /n` �rte,,, 4 E1 VED <br /> l ,U b JUN 6 2008 <br /> ENWRON4COUNTY <br /> HEALTH DEPgEN <br /> TM <br /> ACCEPTED BY: d Ll U �t EMPLOYEE#: D 3 L DATE: Ok <br /> ASSIGNED TO: 11-4" EMPLOYEE#: S 3 to,(� DATE: � � or/ <br /> Date Service Completed (if already completed): SERVICECODE:_5-2-2- Pt :'Alo©� <br /> Fee Amount: S Amount Paid b Payment Date p <br /> Payment Type Invoice# Check# 2 1 U Received ey rR� <br /> &02-025 SR FORM(Golden Rod) <br /> _VISED 11/17/2003 <br />