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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l <br /> OWNER/OPERATOR �I 1 iT �v'e l CHECK If BILLING ADDRESS <br /> n <br /> FACILITY NAME I <br /> ivo <br /> SITE ADDRESS 15J J �CWo <br /> Q� � ( :10n umber DI on treat Name \`- Ci( L 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 /> (204) 6% - yI <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 07-0 -=S (A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR uja f v- 190UJW�S <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPC<` " ro + PHONE# ^Z Exr. <br /> 1 1 1/1rt�t PY��t � 'O Z L/ <br /> HOME or MAILING ADDRESS FAX# <br /> (!$c LolNv✓` '� 3AJd� (3&q 1-123-22 -7Z <br /> CITY v;e.tel STATE (11/4 <br /> - /4 ZIP 1;,6 3 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 <br /> or 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,Standardts,, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �/V DATE: I c) I/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLicANT is not the BILLING PAR7Y 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: „,J nA CJe <0ilt �„ C� <br /> COMMENTS: REC`EIV e /� <br /> Nov 1 B 2004 <br /> SAN JOAOum CO L” <br /> ENVIRON MEI.1T <br /> ACCEPTED BY: D L U E I EMPLOYEE#: O 3IHDATE: f/ O <br /> ASSIGNED TO: v c,N FLL, t EMPLOYEE#: 931-7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( `?(� P i E: ;Z3..c1 <br /> Fee Amount: -/q, �; Amount Paid 9. 71, C� D I Payment Date J D l <br /> Payment Type Invoice# Check# 3 ;L?q-o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />