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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' AOL SERVICE REQUEST <br /> Type oLusiness or P Operty FACILITY ID# SERVICE REQUEST# <br /> --a?01,539 <br /> OWNEIO OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 1,31 L / (14(�1 J 66 <br /> Street Number Direction St et Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number treet a e <br /> CITY �� STATE( � ZIP <br /> r <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> r30-sz <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE ExT' <br /> HOME Or MAILING ADDRESS /��---� � Fly/ ) l` <br /> CITY ( STATE ZIP <br /> v i <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,r/Z� <br /> DERALlaws.APPLICANT'S SIGNATURE: DATE: & /0% J A <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BiLLING PARYT 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: L S -T- R--E-—(Y--.e>'P r �— RECEIVED <br /> COMMENTS: AUG 7 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �C-[ I/Ci.t EMPLOYEE#: 03 24 DATE: 7�0 7 <br /> ASSIGNED TO: �J�J EMPLOYEE#: S(�c f DATE: C V0J <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: z3 o <br /> Fee Amount: �� 8 U Amount Paid t o I 60 Payment Date 1 7 <br /> Payment Type V1.4 Invoice# Check# -)-Lf <br /> Recei ed By: <br /> EHD 48-02-025 $RORfiA(�oldn Rod); <br /> REVISED 11/17/2003 <br />