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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 14 <br /> • SERVICE REQUEST <br /> Type ofsiness or roperty FACILITY ID# SERVICE REQUEST# <br /> t I � ,3 /3 ZC)G <br /> OWNER PERATOR <br /> J CHECK If BILLING ADDRESS❑ <br /> FACILITY NAMEU,'w A-ku <br /> / <br /> 1 <br /> SITE ADDRESS / ��►�j 1� (/�' /Y <br /> Street Number D action j I""� St�et e vVi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE ffl / — EXT. APN# LAND USE APPLICATION# <br /> 4� � 1C/PHONE#2 EXT. BOS DISTRICT ( LOCATIOPI CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ,qL. PHON'? ��ExT. <br /> HOME Or MAILING ADD C FAx# / <br /> CITY STATE ZIPqJ <br /> BILLING ACKNOWL DGEMENT: 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,Standard , •TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1 /C <br /> IfAPPLiCANT 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. nq <br /> TYPE OF SERVICE REQUESTED: LA-`S <br /> COMMENTS: QveD <br /> JUIV 18 2007 <br /> NVfjoNIN COUNT <br /> 16A:Hof rM <br /> ACCEPTED BY: Ly(Li�f�J EMPLOYEE#: 2 / DATE: "-8' ()7 <br /> ASSIGNED TO: �� � _ EMPLOYEE#: �l 5� DATE: 07 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 2-3. Of <br /> Fee Amount: - Amount Paid Payment Date Vt 15 O <br /> Payment Type Invoice# Check# - Receive By: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />