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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTI r"EPARTMENT <br /> SERVICE REQUEST <br /> Type of B 'Hess orP operty FACILITY ID# SERVICE REQUEST# <br /> c�u - 00 co y 8a-a <br /> OWNER/dPERA1kR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME, <br /> q-J5 <br /> SITE ADDRE <br /> , <br /> Street Number I Direction Street Name Zi 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 /> i. > 339— <br /> PHONE#Z EXT. DISTRICT LOCATION CODE <br /> r <br /> 71 <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME i 0 <br /> PHONE') / ` xr. <br /> U <br /> HOME or MAILING ADDRESS FAX# <br /> Ciil ^ '7/?;'A0 STATE ZIP <br /> BILLING ACKNOWL DGEMENT: 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,Standard , TATE and FEDERAL la S. <br /> APPLICANT'S SIGNATURE: DATE: 'r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLiCANT 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. p"AY <br /> TYPE OF SERVICE REQUESTED: S CFiVE <br /> COMMENTS: OV r 2005 <br /> S N��AQUIN <br /> �EACTN QF qa 7-AL- <br /> ACCEPTED B E LOYEE#: ,/ DATE: <br /> ASSIGNED TO: ^ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: 2� <br /> Fee Amount: Amount Paid �q Old Payment Date \\ OS <br /> Payment Type Invoice# Check# Received By: <br />