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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type cBusiness or Property FACILITY ID# SERVICE REQUEST# <br /> L=ka e- , D LI-S � �J SLCM 44 -7 2- <br /> OWNER/OPE, OR - <br /> CHECK If BILLING ADDRES1-1Z <br /> FACILITY NAME <br /> SITE ADDRESS C <br /> Street Number Direction / tre t m i Zi 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 /> ( 2z'I) .C, i <br /> PHONE#2 E)cT• BOS DISTRICT LOCATION CODE <br /> (2y, 2-,YTe' ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Y r e,J CHECK if BILLING ADDRESS <br /> // <br /> BUSINESS NAME l --�/ J PHZ-e� _7 4V1 <br /> ®1,2�Ex r. <br /> HOME or MAILING ADDRF ✓ FAX# <br /> CITY �' �j f STATE ZIP C S L <br /> r <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,STATE a ED <br /> APPLICANT'S SIGNATURE: DATE: �/ 1 <br /> PROPERTY/BUSINESS OWNER❑ �eBIELIILG <br /> A R/MANAC ❑ OTHER UTHORIZED AGENT C�.q/ J �'��•T� <br /> If APPLICANT is n PARTY p of of authorization to sign: is required Tire <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: 64 S 7— 2 1-770V,� <br /> COMMENTS: PA <br /> RECEIVED <br /> NOV 2 4 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: U,e-1 V EMPLOYEE#: 03 Z, DATE: i( Z- <br /> ASSIGNED TO: OctV EMPLOYEE#: SO DATE: !L 2`i ro <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:CS q <br /> Fee Amount: 42�7(i`.0> Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />