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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> la-S E <br /> OWNER/OPERATOR <br /> �� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME / �5!T-5 0 <br /> SITE ADDRESS /( I-7 LA-),, �j� �M� i (?6.2o3.�'Dcc�� <br /> Street Number Direction Street Name city Zio Code <br /> HOME Or MAILING AjDR/EOC/r'—SS (if fDfifferent from Site Address) <br /> / _ w Street Number (� Street Name <br /> CITY LA ePA-L4-AA <br /> STATE C4 <br /> ZIP qv 2 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> > <br /> (2-o y (�2-- t+ l� <br /> PHONE#2 ExT• BOS DISTRICT ][LOCATION CODE <br /> (979 ) 7-7F -0763 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> eL^ I M l L-� iL CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> i� J T f" C Ze5 ) X61-6 33 7 <br /> HOME or MAILING ADDRESS FAX# `/ <br /> CITY C-f`-Mo STATE (! n ZIP 1�S-10 S <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 busts ess as identified on this form. <br /> I also certify that I have prepared thi�application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: ? U`� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT-P Cr <br /> LUL 60AZ to A. <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. 4 <br /> tv <br /> TYPE OF SERVICE REQUESTED: CEIV ECS <br /> COMMENTS: SUN � � 2006 <br /> SAN JOAQUIN cobs <br /> NEALTH DEPAR MEN' <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: o EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid , GD Payment Date \o <br /> Payment Type ✓f Invoice# Check# ` ` Received By: <br /> EHD 48-02-025 SSR FQF�M( oli en'Rod) <br /> REVISED 11/17/2003 <br />