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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPE TOR <br /> CHECK If BILLING ADDRESS <br /> 3 <br /> FACILITY NAME,--L I <br /> . .G� <br /> SITE ADDRESS is/u'4 �� '.. <br /> Street NuMbeer Dire t�ion `'�—W Stree N city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYn"80�� C w$TATE Cl ZZ,P0 <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME . PHONE# 41> o ` O t- <br /> HOME or MAILING ADDRESS FAx# (�• <br /> ( <br /> )':�'thts t' <br /> CITYSTA 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 law . <br /> APPLICANT'S SIGNAT DATE: ' <br /> PROPERTY/BUSINESS OWNER ElOPERATOR/NIANAGER ElOTHER AUTHORIZED AGENT��4 <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: PAYM E N T <br /> rN -2,n RECEIVED <br /> FEB - 8 2007 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: -EMPLOYEE#: HEA PAR C <br /> ASSIGNED TO: EMPLOYEE#: %. DATE: <br /> Date Service Comple i al ready completed): SERVICE CODE: v� PIE: Q O <br /> Fee Amount: U Amount.Paid — Payment Date a g' J <br /> Payment Type �j Invoice# Check# Received By: <br /> EHD 48-02-025 ' .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />