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NANJOAQUIN UOUNTYENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Typp of Ek sjness or Property FACILITY ID# SERVICE REQUEST# <br /> q <br /> OWNER 1 OPERATOR 1r • 11 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME V lLr <br />} SITE ADDRESS 2 S Sg~ W DQ4 V) t, r�l� <br /> I <br /> Street Number Direction Street Name Ci Zi Code <br /> r HOME Or MAILIN�GjADDifferentDRESS (If Different from Site Address) <br /> 02 A <br /> ` / Street NumberF Street Name <br /> CITY STATE ZIP 7 <br /> i7] s �!r <br /> h <br /> PHONE#1 EXT. APN# z <br /> LAND USE APPLICATION# <br /> OBS —3 - 1 <br /> 1 I4 -.Oto �- 2-1-5, C�4S <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR �'�' d�p CHECK if BILLING ADDRESSE] <br /> ✓) lco, <br /> BUSINESS NAME PHONE# EXT. <br /> HomE or MAILING ADDRESS FAx# <br /> a- r tit/ (;Lot 2 3 7 3 <br /> CITY be <br /> j 0 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, ST <br /> T_Alf and FEDERA aws. <br /> APPLICANT'S SIGNATURE: DATE: T G 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT L'S �l V�L ��✓'¢+� <br /> t 1fAPPLICANTis not the.BiLLINGPARTY,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 /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. / OOS — 0--Z <br /> TYPE OF SERV� 'ICtE REQUESTED; o yy Ccrj Sp �' 8�f� S�Js( �J <br /> COMMENTS: jr/ a! t-p evr4t. ��� J !l(/"'� VWf <br /> JUN 19 2007 <br /> Agle-lY SAN JOAQUIN couNTY <br /> "'"rl ENVIRONMENTAL <br /> LI t-I yyTT� <br /> ACCEPTED BY: t-10 9 t EMPLOYEE#: �( SJATE: ( O <br /> ASSIGNED TO: IL-(F—eJ f AJ4 EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICECODE: �ZZ P t E: n r <br /> Fee Amount: f Amount Paid t 60 Payment Date b <br /> Payment Type Invoice# Check# 3 3 Received By: <br /> EHD 48-02-025 SR FORM poliieri Rod) <br /> REVISED 11/17/2003 <br />