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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> z�� r sRo a 14 4?SS9 <br /> OWNER/ OPERATOR 1 <br /> CHECK If BILLING ADDRESS D <br /> FACILITY NAME <br /> SITE ADDRESS 43? A) (A)l 6J--J.I �jTpGIC ED�^ �SZ�S <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 /> ( ) <br /> /,S-/ - 130- Z <br /> PHONE#2 EXT. BOS DISTRICT j LOCATION CODE, <br /> ( ) l L L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4�mI <br /> CHECK If BILLING ADDRESS <br /> HIM t�f 60. - 661ul <br /> BUSINESS NAME / PHONE# EXT. <br /> y abri > 67- 25 <br /> HOME or MAILING ADDRESS ,^ FAx# ) <br /> CITY / TATE IP / <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,kTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATES:/�--� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CJ <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: a-`t-772 r—t T PAYMEN-i <br /> COMMENTS: D <br /> JAN 3 0 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: S DATE: ! J U - <br /> ASSIGNED TO: t V EMPLOYEE#: C j Z/ DATE: 3o <br /> 0 <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> 3.L <br /> Fee Amount: Amount Paid a C S Payment Date \ 3 1 <br /> Payment Type Invoice# Check# 5 Received By: <br /> EHD 48-02-025 'SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />