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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />0 SERVICE REQUEST • <br />Type of Busines orproperty <br />FACILITY ID # <br />PHONE E><r. <br />yLPI - �3 <br />SERVICE REQUEST # <br />Ll Alk L <br />CITY L,. /l STATE IP <br />ACCEPTED BY: <br />0Lt t/F LEMPLOYEEM <br />OWNER/ OPERATORr -- <br />1 A I�11 <br />DATE: �3 <br />CHECK If BILLING ADDRESS <br />AJ <br />EMPLOYEE #: P• -7s ?j <br />DATE: <br />FACILITY NAME I , <br />(if already completed): <br />SERVICE CODE: 14g <br />SITE ADORE S <br />,0 Street Number <br />irection <br />Fee Amoun <br />eel NRrhe r <br />Amount Paid <br />d�� <br />Payment Date <br />Payment Type <br />HOME or MAILING ADDRESS If Different from Site Address) <br />Invoice # <br />Check # 1 D'2- q p <br />Received By: <br />,�—f l <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />P ONE#1) ^ _ , EXT. <br />`-•/rte/l <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Ems' <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR' <br />1 CHECK if BILLING ADDRESS <br />BUSINESS NAME i <br />PHONE E><r. <br />yLPI - �3 <br />HOME Or MAILING ADD ESS l <br />Al <br />CITY L,. /l STATE IP <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 a pli 4cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar s, STATB-J�RAL <br />APPLICANT'S SIGNATURE: S f Il/CQ / i DATE: Il �I,,/ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT . Lit' lj r`C' % <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 />infomlation 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. MAvn A F NT <br />TYPE OF SERVICE REQUESTED: KSr/— �I��%,0 <br />(T— <br />RECEIVED <br />COMMENTS: <br />NOV 2 3 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />0Lt t/F LEMPLOYEEM <br />�'j)� <br />DATE: �3 <br />ASSIGNED TO: <br />AJ <br />EMPLOYEE #: P• -7s ?j <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: 14g <br />PIE:Z3 �dP <br />Fee Amoun <br />1'1� , pL7 <br />Amount Paid <br />d�� <br />Payment Date <br />Payment Type <br />/ <br />Invoice # <br />Check # 1 D'2- q p <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />