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NTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST • <br />Type of iness or r p rty <br />CHECK if BILLING ADDRIAr F1 <br />FACILITY ID # <br />. SERVICE REQUEST # <br />ExT. <br />HOME or MAILING ADDRESS <br />FAX# <br />ACCEPTED BY: v L. 100 �p . <br />Skou'sDd 2-4 <br />OWNERO/ OPERATOR <br />52 <br />DATE: 3 ! p Q .-7 <br />ADDRESS <br />A'y <br />DATE: _3 t l E <br />(� <br />CHECK if BILLING <br />FACILITY NAME <br />SERVICE CODE: / � t <br />ff <br />P I E: <br />Fee Amount: 0_� <br />SITE ADDRESS <br />//57/ /,"�. <br />Payment Date <br />1 Q <br />Payment Type <br />Invoice # <br />Street Number <br />erection <br />Street Name <br />Ci Code <br />HOME or MAILING <br />DDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />P97) 07C:e-,1,3 <br />� got/ <br />PHONE #2 <br />EXT. <br />BOS DISTRICT.. <br />LOCATION CODE <br />L <br />( ) <br />_� <br />C <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRIAr F1 <br />BUSINESS NAME <br />PHONE# <br />ExT. <br />HOME or MAILING ADDRESS <br />FAX# <br />ACCEPTED BY: v L. 100 �p . <br />CITY STATE <br />IP <br />52 <br />DATE: 3 ! p Q .-7 <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 thM-7nil& <br />d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandarEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN_P� <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. <br />TYPE OF SERVICE REQUESTED: S %% <br />F3 / <br />rHT IVICIV I <br />R ECE I <br />COMMENTS: <br />MAR 1 9 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HFAI_TH DEPARTMENT <br />ACCEPTED BY: v L. 100 �p . <br />EMPLOYEE #: <br />3 Z, f <br />DATE: 3 ! p Q .-7 <br />ASSIGNED TO: AJ t Y' Lk- <br />EMPLOYEE #: <br />DATE: _3 t l E <br />(� <br />Date Service Completed (if already completed): <br />SERVICE CODE: / � t <br />P I E: <br />Fee Amount: 0_� <br />Amount Paid S S, ou <br />Payment Date <br />1 Q <br />Payment Type <br />Invoice # <br />Check # <br />`t q l <br />Received By: <br />EHD 48-02-025 SR FARM "(Goddn Rod) <br />REVISED 11/17/2003 <br />