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NAN J OAQUINI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />6 SERVICE REQUEST 0 <br />Type of Business or Property <br />t <br />FACIL{TY lD # <br />SERViCE REQUEST # <br />OWNER C)PERATOR�1 <br />� 2 201 <br />AUG <br />Ootyo v <br />CHECK ifBILLINDRESSL� <br />SA jy ,f0 QUtit� A <br />�OMCp,�WCOX <br />1v1V <br />-GAD <br />FAC]LrrY NAME <br />'EMPLOYEE #: <br />DATE: i °- 'rCr <br />ASSIGNED TO: <br />�Ir <br />SITE ADDRESS <br />(A � <br />� � `' <br />�} h r <br />1 I l�� y l ��L� <br />CP - T 5�)Y� <br />l `-' <br />Street Number <br />1. <br />Direction <br />Street Name <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type Invoice # <br />Cheek # �� <br />Received By <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 <br />EXT' <br />APN # <br />LAND USE APPLICATION # <br />PHONO2 <br />Exr• <br />BflS DISTRICT <br />LOCATION 90DE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME� � � _ J �nc �H E� Exr. <br />9 V <br />HomF- or MAILING ADDRESS ��FAx # �t <br />5cJ�` W ` \ Wrrtj� . <br />CITY G ; x AL/ rAn n to a C:�, 0^C�� STATE ZIP <br />-NLa► ► v c— <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of salve, <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 forth. <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. G <br />APPLICANT'S SIGNATURE: 9f� l j DATF—-- <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ AIANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICAN'T 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 />nrnvided to me or my representative. <br />TYPE OF SER Qt1E5TED: �(� A, <br />t <br />CO <br />� 2 201 <br />AUG <br />Ootyo v <br />SA jy ,f0 QUtit� A <br />�OMCp,�WCOX <br />1v1V <br />144 <br />A TEO BY:M . ! <br />f " <br />'EMPLOYEE #: <br />DATE: i °- 'rCr <br />ASSIGNED TO: <br />�Ir <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P ! E: Q <br />Fee Amount: 'L C)� <br />J <br />Arnoun# Pal�� <br />PaymentDate gay <br />Payment Type Invoice # <br />Cheek # �� <br />Received By <br />0V W - hl� n'Ftad}' <br />EHD 48 Cf2-025 a <br />REVISED 11/17/2003 <br />