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SAN JOAQUIN COUENVIRONMENTAL HEALTH DEP MENT <br /> P'T <br /> RVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> I U� C� / I � �Q � � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME w / <br /> SW nene_ 6aPclpon . T <br /> SITE ADDRESS /U <br /> �7CA (��f Lcal rC/� <br /> 12 70.5 ,� f am <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> h Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATI N CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR S �� <br /> i L CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> r ( ) <br /> CITY 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE�C�/, (' ��/ l DATE: /�Z191 7PROPERTY/BUSINESS OWNER,F✓U OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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: =�'�� <br /> COMMENTS: R ECEI V EGA <br /> DEC 19 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAELNT <br /> ACCEPTED BY: ,l EMPLOYEE#: DATE: <br /> ASSIGNED TO: G 1f/ EMPLOYEE#: �G�� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P I E: v 2i <br /> Fee Amount: 1 b �� Amount Paidrc7� Payment Date N-Z' ` 01 <br /> W <br /> Payment Type Invoice# Check# 07 1-k Received By: . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />