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I 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> I SERVICE REQUEST <br /> t Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> C rA� _ [,j J�f/�j s CHECK If BILLING ADDRESS <br /> St <br /> FAciuTY NAM E /� <br /> rSRI=ADDRESS [ 126,)h-- <br /> D Street Numberib rection Street Name Gi Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) � (3� <br /> 4Z--30 O tr A L-�Jp Street umber Street Name <br /> CITY i 3AB STAT QIP q 5 <br />{' T. A?N# LAND USE APPLICATION# <br /> r <br /> PHONE I + U' t✓1`D�C7� ®g+`C, ' P �-�� '7tv0 <br /> q <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �� �✓► v ,�� CHECK if BILLING ADDRESS <br /> BUSINESS NAME � \ � PHONE# Err, <br /> t>I LLo/-' C' u�. -2,1,11 <br /> HOME or MAILING ADDRESS FAX# <br /> E :R 6, ,< I Z�) 34- 0-7 Z--3- <br /> CITYr t A o_/STATE ZEP. 4 <br /> BILLING'ALC'KNOVWJLEDGEMENT: 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 /> r <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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rds,STATE and FEDERAL laws. ) <br /> f APPLICANT'S SIGNATURE: DATE: A,/: <br /> PROPERTY/BUSINESS OWNER❑ O BATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Ll{Z 6 I I 1 L f;" ez <br /> 4 <br /> IfAPPLICANT is no e B LING 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 /> i 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: ss i S S40 I r 'S' PA <br /> COMMENTS: 60 JLS S JL/-ry <br /> ('/zolq t.i I��b c� MAY 17 2007 <br /> pt"P� R sAty daAC�UIN GoUIdTY <br /> n/. , C C671c7 ENV1ROtVMENTAL <br /> HEALTH DEPARTMEM <br /> _ A- . <br /> ACCEPTED BY: EMPLOYEE#: DATE: y�`f <br /> L - <br /> ASSIGNED TO:r ti /ti EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: y PIE: <br /> Fee Amount: 011 0Amount Paid Q O , a) Payment Date S t <br /> Payment Type Invoice# Check# $ 1 ,7 Received By: t <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11!1712003 <br />