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SAN dOAQUINIOUNTY ENVIRONMENTAL HEALTH DT.MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNE&g,I OPERATOR CNEcK if SBJJNG ADMESS❑ <br /> Yd-f/ J"u e <br /> FACILrrY NAME t4J.'j <br /> C4 <br /> ro✓� evr'o.'7 <br /> Sy 3 ofNu /V !.✓:/rte <br /> s t e ' ° <br /> HOME or MAILWG ADDRESS (If DWarent from site Address) <br /> Street Number Z <br /> CITY STATE zip <br /> PHONE#1 Exr• APN* LAND USE APPLICATION# <br /> PHONE#2 EKT. HOS DISTRICT LOCATION CODE <br /> Pd-7l <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQuESTOR CHECK if BILLNGADDRESS❑ <br /> C"41.r -k <br /> BUSINESS NAME.,/ CPHONE# T'7yO <br /> l.h�IYI 1d+'I lorei,r/dh !eS t � �� <br /> HOME or MAIuka ADDRESS P,p Leo (�3 `!' FAX# 71/7 5t <br /> 1�s6 ) 31f 3 <br /> CITY STATE c a, ZIP <br /> IIILLING ACKNOWLEDGEMENT_: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that an site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to nate or my business as identified on this form. <br /> I also certify that 1 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,STAE and FEAERAL I• s. <br /> 0141, <br /> APPLICANT'S SIGNATURE: ,r ]DATE' <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGE[t ❑ OruxRAuTnowzEDAGENT <br /> [Ei <br /> If APPLICANTIS not the BILGING PARTY.proof Of authorization to sign t9 required !1 t d e <br /> AUTHORIZATION TO RELEAS>l':INIIORMATION: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. J/ �- <br /> TYPE OF SERVICE REQEST <br /> UED: Ae:i'r'O T f <br /> COMMENTS: �f./�/A(G� c;,z/y LGlaf 3"F'_/1Sor'S c✓I C'au f-141, . F120IGIt,Q RF4 <br /> qv <br /> Qh d'r��► -f'�nlr Nov 2 1 2006 <br /> SAN JOAQUIN COUNTY <br /> ENV►RONM ML <br /> RTMENT <br /> AcciimDBY: EMPLOYEEM 03� l <br /> DATE: 1 Z--1 <br /> A98113NED TO: EMPLOYEE#: 9 I S s DATE: 11 Z- to(,, <br /> P I E:- <br /> Date Service Completed (If already completed): SERVICE CODE: (�P'� � 3,C,&' <br /> - <br /> Fee Amount, S'.5 •c=am Amount Paid $ S Payment Date \\J2--i <br /> Payment Type\) � S <br /> Invoice# Check# Received By: <br /> Golden Rod)SR FORM <br /> eHo as-oz-azs ( <br /> REVISED 11117/2003 cja' p Z'101$ <br />