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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTavEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# .SERVICE REQUEST# <br /> tw <br /> U 5T- <br /> OWNER/OPERATOR <br /> J P� CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 60�3 ` T(Q 44- !J�11CT� J jQ•�4 C(�. �C'�j7� <br /> Street Number Direction I Street Name city Zip Code <br /> OME or MAILING ADDRESS If Different frolite Address) <br /> Street Number Street Name 657-D / <br /> CITY,— STATE ZIP <br /> Y` <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (4aV q6Lt ? <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> `3 (_t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> ) <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 anal that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and F� RAL 1 WS. <br /> APPLICANT'S SIGNATURE: DATE: 1 T �a <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER THER AUTHORIZED AGENT 11If APPLICANT is not the BILLING ARTY 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Y` + HECEIVED <br /> C <br /> COMMENTS: j OEC - 3 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: i EMPLOYEE M (71, � DATE: <br /> ASSIGNED TO: � EMPLOYEE M 2� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 2,3) 1 <br /> Fee Amount: Amount Paid !O S.oD Payment Date 1 3 O8 <br /> Payment Type Invoice# Check# G D Q �— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />