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SAN JOAQUP" r`OUNTY ENVIRONMENTAL HEALT ;DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> 'gREQUEST# <br /> Le UlCa�rJ 7Y2eOVr � 73 <br /> OWNER/OPERATOR <br /> / CHECK If BILLING ADDRESS <br /> FACILITY NAME G� - <br /> SITE ADDRESSP <br /> .j0 Street Number Direction Street Name I�rrl city Zip Code <br /> HOME or MAILING ADDRESS (If Diiffe`rent from Site Address) <br /> �-K Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ` ET. APN# LAND USE APPLICATION# <br /> (.&g) 1/" o- G <br /> PHO,N,EE##2 / ET. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING <br /> /ADDRESS <br /> BUSINESS NAME 'J `C C/ PHONE# 6�.Srb Exr. <br /> a•m er � <br /> HOME or MAILING ADDRESS FAX If <br /> G ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: f�/r Ln/� � �o� DATE: 08 — 17 — O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <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: 0 0 .J_S[.L.t.'�k��7 U'IJ I EE' ED <br /> COMMENTS: AUG 1 QO 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C . _ L E I I EMPLOYEE# C.321 DATE: <br /> ASSIGNEDTO: ;� H i EMPLOYEE#: `73,k-C DATE: <br /> Date Service Completed ll(if already completed): SERVICE CODE: PIE: <br /> Fee Amount: C Amount Paid 1$ 4 3 0 Payment Date p 5 <br /> Payment Type % Invoice# Check# Received By: <br />