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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> on <br /> OWNER/ OPERATOR <br /> � 1 n\ �G CHECK If BILLING ADDRESS <br /> +- <br /> MITY <br /> FAKCk—YE <br /> SITE ADDRESS a i (� Y'�171�� c�F_ L�rDC K400 C LJ Ci <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Q9 ) q31 <br /> -G1 GS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURET,' ''S��/�Z� DATE:- <br /> PROPERTY/BUSINESS OWNERP OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING 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 /> 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: (2,,) <br /> COMMENTS: PAYMENT PAYMENT <br /> RECEIVED RECEIVE[ <br /> MAY 3 1 2006 .,,At 3 1 2006 <br /> SAN JOAQUIN COUNTY SAN JOAQUIN COUN Y- <br /> ENVVIHRnONMENTAL, <br /> ACCEPTED BY: EMPL &FM DEPVIA J-p T11 H IIjjjE� rA <br /> b <br /> ASSIGNED TO: yyk 2-e— EMPLOYEE#: , o 0 DATE: 0 In� <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: t" ,; - Amount Paid Payment Date f <br /> Payment Type �, Invoice# Check# R4ceive By: f�7 <br /> EHD 48-02-025 ` .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />