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SAN JOAQT"N COUNTY ENVIRONMENTAL HEA] —I DEPARTMENT <br /> SERVICE REQUEST <br /> Type Qf Business or Property FACILITY ID# SERVICE REQUEST# <br /> Re un 5r2 00 311tj10 <br /> OWNER/OPERATOR <br /> CHECK 11 BILLING ADDRESS <br /> 91/L <br /> FACILITY NAME <br /> SITE ADDRESS N, 44 �2�7!� _ �f f r <br /> �6G <br /> DC Street Numb" Dimclion - Street Name J C L�GCvil Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> �- <br /> 6U Slreat Number Sveet Name <br /> CITY STATE ZIP <br /> z <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR Au� Q( „In Yl CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# / EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> /' <br /> CITY G G ,K J 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 Codex,Standards,STA9Ti and FEDERAL laws. <br /> APPLICANT'S SIGNA.4; �� }�i� DATR: E3 <br /> PROPF.RTYI BUSINECS OWNER PF. TOIL/MANAGER ❑ t AUTIIDRIZF.D ACRNT❑ <br /> /f APPLICANT is not the QILI./NC PARTY proof of authorization to sign is required Tide <br /> AUT11ORIZA11ON 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, geoteclmical data and/or environmental/site assessment <br /> infornTation to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTII DEPARTMENT as Soon as it is available and at the Sante time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MAY 3 0 2003 <br /> L 7� z-O ,/ ✓�`� Y���',�n/� ,,[ SAN JOAQUIN COUNTY <br /> % 7 03 ✓ El 7gN✓ EIC�E L H[�TH SERVICES <br /> SION <br /> APPROVED 9Y: EMPLOYEE#: L ( DATE: T <br /> ASSIGNED TO: fL EMPLOYEE M DATE: V <br /> Date Service Complete (ifalready c pleted): SERVICECODE: O PIE: <br /> Fee Amount: Amount Paid 1 Payment Date �5'Pi <br /> Payment Type Invoice# Check# V— Received By: <br /> EHD 4R-O7-025 SERVICE REO <br /> REVISED 6.5-02 - <br />