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` SAN JOAQUII UNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATQJR <br /> CHECK If BILLING ADDRES <br /> FACILITY NAME <br /> SITE ADDRESS 7j I S E7. it_L..M <br /> SEreet Number Direction � -- '" '��S�t Name � � —C�'i l(] � Zi 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# r �o LAND USE APPLICATION# <br /> ( ) 12(oy7— � <br /> if <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IAyo 1� <br /> Yrl� J CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE EXT. <br /> h � �5= � <br /> HOME Or MAILIN0 �l"/Il.RESS,w � ( r c� <br /> � *�'• � ',� y <br /> CITY 141Z� STATE i **' ZIP S-2 S✓3 <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 aDolication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TA and FEDERAL-laws. <br /> APPLICANT'S SIGNATURE: r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN <br /> IfAPPLiCANTis 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 representativ . <br /> TYPE OF SERVICE REQUESTED: VJ 7f R �.I Cp <br /> COMMENTS: C PAYMENT <br /> x RECEIVED <br /> SEP 2 4 2008 <br /> SAN JOAQUIN CI,OUANEN <br /> ACCEPTED B ' ' EMPLOYEE#: DEPA q 2 <br /> ASSIGNED TO:C— crr EMPLOYEE#: DATE: 6 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 417.2 Amount Paid q-7a.5-b Payment Date C7 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />