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SAN JOAQUIOUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR J� <br /> S L��� ©n I I J ay— CHECK If BILLING ADDRESS❑ <br /> FACILITY(NAME � n � � C) <br /> SITE ADDRESS �l I a / –.e Co'– q S3 3�O <br /> 4 5-1)0 Street NumberDirection Street Na 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 /> (duq) ga�- (.133�- — U 1- <br /> PHrrONrrEJJ#2 EXT. BOS DISTRICT LOCATION C DE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ��J <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> P- rJr1-)lC\'ktiy, se'yvi ce S I1V)C• ()6 q) 914S-9's'8 <br /> HOME or MAILING ADDRESS FAX# <br /> �� �ra►�c� �v ---rv� sl-- ( d 9) 8 I/s <br /> G'�d at STATE ZIP 9S <br /> CITY /1 <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,Standar s, STATE and FEDERAL laws. <br /> D <br /> APPLICANT'S SIGNATURE: A `Q,, DATE: 1 11 art <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ly (I MNCR y9 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required illtle <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: I f- — <br /> Ulu <br /> COMMENTS: <br /> RECE+�1�+T <br /> V�b <br /> DEC 12007 <br /> SAN jo A <br /> ACCEPTED BY: Lf EMPLOYEE#: � 11AL ENTA <br /> ASSIGNED TO: / EMPLOYEE#: ; . I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / g- P/E: <br /> Fee Amount: #" Amount Paid ,. 9�, D LJ Payme t Date t.)-11 I J 1)'7 <br /> Payment Type Invoice# Check# p 7 Received By: { <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />