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f SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I�� 000 (oK`1'3 1:3-izoO 14 4o -3e�q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 7 <br /> �:;Bamber 1 Direction v Me6t Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stmt Name <br /> CITY STATE ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#Y ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# Bur. <br /> HOME or MAILING'ADDRESS FAX# <br /> ( I ) •, <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 <br /> or 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -� DATE: <br /> ,.= l%1)flC� <br /> PROPERTY/BUsiNESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AuTnORi7EDAGENT J0 Z :g -�L/� <br /> If APPLICANT is not the BILLING PARTY,proofofauthorization 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: !� �{��M� <br /> COMMENTS: R�� <br /> APR 1 � 2006 <br /> cpuN0 <br /> S JO NME MENT <br /> EN pEPP <br /> ACCEPTED BY: R (v,�J EMPLOYEE#: p t DATE: <br /> ASSIGNED TO: '\ KJ / 1 EMPLOYEE#: D DATE: '(11,0166 <br /> Date Service Completed (if already completed): SERVICECODE: 14-18 P t E: 2308 <br /> Fee Amount: v Amount Paid 2 .0 u Payment Date W/o <br /> Payment Type Invoice# Check# "G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />