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SAN JOAQU)*UNTY-ENVIRONMENTAL HEALTH OPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 0-n D ccs 4 11 I l � t -S # -] Q S CLL L <br /> SITE ADDRESS <br /> /2F>b 2a�c61 AGName Y 95zfO <br /> Street Number DlreeHon Street Name CI ZID Code <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 USEAPPLICATION# <br /> b"' f) LI-7 _ ALLi 07 <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR ttt� (�Or-� t <br /> 2 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> O $ /Z� <br /> HOME or MAILING ADDRESS FAX# <br /> 77 Ga R ) Z& IS 3 <br /> CITY STATE ZIP 1-04U CH9 's <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: DATE: S-�-U/w <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q 1,f4 t Co /r(C/,vCC2 CLQ/ <br /> I,fAPPL/CANT 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 environmentaVsite assessment <br /> information t0 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: SL <br /> COMMENTS: <br /> k AY 9 2006 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> ACCEPTED BY: EMPLOYEE#: Yb DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Q <br /> Fee Amount: Amount Paid Payment Date 5 0 <br /> Payment Type Invoice# Check# Received By: a G, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />