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SAN JOAQUOUNTY ENVIRONMENTAL HEAL EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />LJ^ <br />Nov 10 2003 <br />5 5 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />i1ou3 <br />OWNER/ OPERATOR <br />APPROVED BY: L <br />CHECK ❑ <br />CA -,s -6 <br />DATE: j <br />if BILLING ADDRESS <br />FACILITY NAME <br />�S 1� �4,Iv �Ltis✓ <br />EMPLOYEE #: S <br />SITE ADDRESS/(�uf <br />Date Service Completed (if already completed): <br />SERVICE CODE: C <br />PIE: +7 �ur <br />Fee Amount:Z <br />Amount Paid <br />Street Number <br />Direction <br />Payment Type <br />Street Name <br />Check # <br />Cit <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Cf <br />v 1 <br />Street Number <br />yl (s,0 ` ret,- Street Name <br />CITY <br />STAT ZIP <br />C"s <br />- X301 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(gLk ) S -qua <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING PbDRESS ❑ <br />BUSINESS NAME PHONE# EXT. <br />( <br />HOME Or MAILING ADDRESS(� II FAX # <br />CC 7 �"" (?07) 678 - ( 530) 7YO-091 Z <br />CITY STATE C4 ZIP / ; G 2,0 <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 ri <br />activity will be billed to me or my business as identified on this form. 1 <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, STATE andFEDERALlaws. <br />APPLICANT'S SIGNATURE: "� DATE: 11/10/03 <br />PROPERTY/ButINESSOwNER❑ OPERATOR/MANAGER ❑ OTnERAUTHORIZED AGENT <br />� <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AU'11-10RIZATION 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 HEALTit DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. f <br />TYPE OF SERVICE REQUESTED: �. f <br />pAYMEN <br />COMMENTS: <br />LJ^ <br />Nov 10 2003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />f1EALTH DEPARTMENT <br />APPROVED BY: L <br />EMPLOYEE #: 0I D <br />I Dr� <br />DATE: j <br />ASSIGNED TO: <br />EMPLOYEE #: S <br />DATE: - <br />Date Service Completed (if already completed): <br />SERVICE CODE: C <br />PIE: +7 �ur <br />Fee Amount:Z <br />Amount Paid <br />(? <br />Payment Date 3 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />PP\/ICF--n a-r_r» <br />