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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 06iR/OPERATOR <br /> eI 1 ��vl./e P1 J/ -a�fi �l J CHECK If BILLING ADDRESS <br /> r L:! �U <br /> FACILITY NAME <br /> SITE ADDRESS c2SI p 3,2 ('0`olnfLh / q ve : U <br /> S reet Number Direction L� Street eName a✓� i �I�' � � ode <br /> HOME or,MAILING ADDRESS (If Different from Site Address) <br /> l�f�� (/V, r� ;�. <br /> Street NumberF RUS <br /> CITY }TATE ZIP <br /> TT01C' l_,;� <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 6 L( <br /> -7✓l CHECK If BILLING ADDRES <br /> BUSINESS NAME ��1 n ��i PHONE# ��j_ O�l U <br /> ExT. <br /> HOME Or MAILING ADDRESSFAx c�S-6 ( �# <br /> CITY e'I n n H STATE C� zip q S-3c0 <br /> J <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 applicati d th the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST a FED L a s <br /> APPLICANT'S SIGNATURE: DATES:( /�'z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/DIANA ❑ OTHER AUTHORIZED AGENT�1 <br /> If APPLICANT 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: S C I lr f Lk t 7yj- A I(_ <br /> COMMENTS: - �{), , � � ENT <br /> 7/)5/7cv� r EIV-p <br /> JUL 2 <br /> 2007 <br /> SAN,10ApUIN COUNTY <br /> H At ORONME <br /> ACCEPTED BY: EMPLOYEE#: DATE: ZM y <br /> ASSIGNED TO: -f—� S I G.101)LC,_o S EMPLOYEE#: �F C y S DATE: -7 <br /> Date Service Completed (if already co leted): SERVICE CODE: S _ P I E: <br /> Fee Amount:- D �p�S: Amount Paid C�' — �. �!� Payment Date <br /> Payment Type Invoice# Check# a� v Received By: <br /> EHD 48-02-025 V � D��F`77 CJ SR FORM'(Golde'n'Rod) <br /> REVISED 11/17/2003 <br />