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NTY L+'NVIRONMENTAL HEALTH DEPARTMENT <br /> • SERVICE REQUEST0 <br /> Type of Bus' ess or Property FACILITY ID# SERVICE REQUEST# <br /> id`s S- <br /> OWNER OP TOR Co <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME <br /> 6 n <br /> CO �/ j� S c5 ,///� <br /> SITE ADDRESS /e/kQo�Arn 155 216 <br /> Street Number Direction jq Street Name C ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) / _DD N• (��,r t/ <br /> O+ Stree Number / Street Name <br /> CITY1S / STATE ZIP !1 ,67 f <br /> PHONE#I ExT APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. B DISTRICT LOCATION CODE <br /> -gal Ph ( ) to,3 — /C/33 11 1 <br /> al, CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / / ,/ <br /> �I � CHECK If BILLING ADDRESS <br /> BUSINESS NAME 'I�1/—�//vIi/T• ` ` T <br /> ♦��'Y7ls�i�i.G ✓y� PHONE#Apq) �3 <br /> HOME or MAILING ADDRESS FAx# (D/ <br /> (0209) <br /> STATE ZIP <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,Standa dSTATE and FEDERAL laws. <br /> APPLICANT'S SIGNAT DATE: //- -7 <br /> 2 //� __�/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENTw s{,fytcw loD'Yd;ACL rT, <br /> If APPLICANT 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. PAYMENT' <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: / NOV 2 6 2007 <br /> f'I Z���,'1 d C� ,_ „� <br /> f t l ab l 1-7 �2 SAN JOAOUIN COUNTY <br /> ( ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: !, / S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: c' Amount Paid ��'1� a Q Payme t Date <br /> Payment Type Invoice# Check# Z 4�� Received By: <br /> EHD 48-02-025 y <br /> 4 ,SR FARM(Goldo <br /> REVISED 11/17/2003 <br />