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SAN JOAQUIPOUNTY ENVIRONIVIENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Slot-4--L C', - 3(0 S F o o 4 9 7143 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITYNAME <br /> SITE ADDRESS <br /> 13 Street Number I Directlan ( Stree ame PsRT Clt Zip Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMES/p� /-(- <br /> BUSINESS /v PHONE# EXT. <br /> HOME or MAILING ADDRESS # <br /> DRESS ` ( FAX <br /> W { �r 7TL �cC ✓r� ( ) <br /> L <br /> CITY I � C) ' STATE a,4 ZIP 6t �2(/U <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 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �O122/111 d< Q> 4/-LDATE: 2— (0'-0-J <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APDL/CANT iS not the BILLING PARTY Proof of authorization to sign is required TIIlc <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 Inc c:my representative. <br /> TYPE OF SERVICE REQUESTED: LAS-f— 4I oW p' t <br /> COMMENTS; RECHWED <br /> FEB tI S 2007 <br /> ENVIRONMENT%W11 <br /> PERMITISEERUM <br /> ACCEPTED BY: EMPLOYEE#: L71 S-3 DATE: 2. W-0-'? <br /> ASSIGNED TO: �/_ EMPLOYEE#: On S 3 DATE: -L-7-o-07 p7 <br /> Date Service Completed (if already completed): SERVICE CODE: « PIE: 23 <br /> Fee Amount: 2$r W Amount Paid Z.-6S .t?D Payment Date o-r <br /> Payment Type Invoice# Check# Rec ived By: <br /> EHD 48-02-025 FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />