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From: 0 12/16006 16:42 #216 P.004/007 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�" <br />CHECK if BILLING ADORESS�r `•. <br />ID # <br />SERVICE REQUEST # <br />PH NE ExT. <br />qL423 <br />HOME or MAILING ADDRESS <br />^�FACILIT((,,Y�� <br />! �U <br />FAx# <br />OWNER I OPERATOR <br />(AL -Po Q `-N 2 C��173 t <br />, CHECK if BILLING ADDRESS❑ <br />FACILITY NAME <br />Y L <br />ACCEPTED BY: <br />SITE ADDRESS f „, 3t� <br />�� <br />ASSIGNED TO: <br />Street Numder <br />Direciho <br />$trait , <br />i <br />'ode <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />_ <br />Fee Amount: s' U�1 <br />Street Number <br />Street Name <br />_ <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />{ y <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�" <br />CHECK if BILLING ADORESS�r `•. <br />BUSINESS NAME . <br />Irl►`t�d <br />PH NE ExT. <br />qL423 <br />HOME or MAILING ADDRESS <br />FAx# <br />L=M- <br />(AL -Po Q `-N 2 C��173 t <br />CITY <br />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 HEALTu DEPARTMENT hourly charges associated with this project <br />or 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, TATE and FiiDERAL laws. <br />APPLICANT'S SIGNATURE: 6AL DATE: t.�- <br />PROPERTY / BuSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIzEi) AGE,%T�w <br />If APPLICANT is not the BILLING PART) proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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, HLAL.TH DEPARTMENT as soon as it is available and at the saute time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: S T e r . ib �- <br />PAS ��1 �f Ea <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />t <br />ENVIRONM <br />i]EPARTMEIVT <br />ViEpLTH <br />ACCEPTED BY: <br />EMPLOYEE#: 31 �] <br />02 <br />DA E: 2 t' Q7 <br />ASSIGNED TO: <br />EMPLOYEE #: r1 .� <br />DATE: , <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1U <br />PIE: <br />Fee Amount: s' U�1 <br />Amount Pald <br />5 <br />Payment Date 1 Z \S l ( <br />Payment Type <br />Invoice # <br />C 'J ZIP <br />Received Sy: <br />EFM 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />