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SAN JOAQUIN4DUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> + SERVICE REQUEST • <br /> FNEs or Property FACILITY ID# SERVICE REQUEST <br /> PERA RotULQ CHECKif BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 a pn <br /> Street Number I�ction (i `Streets a r C I 4)"— <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number SreetN a <br /> CITY ` STATE zip <br /> 06 1 . -T � <br /> F PHONE 1 E%T• APN �# ILAAD USE APPLICATION# <br /> PH3 _ ExT' BOS DISTRICT LOCATION CODE <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST R i l/-A,✓/ CHECK If BILLING ADDRESS <br /> BUSINESS NA rlr�9/ PHONE ,. FXT• <br /> HOME Or MAILIN AD RESS ^�.- F # <br /> CITY STATE zip <br /> J`F�DJ <br /> BILLING AC DGEMENT: 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 busin s s identified on this form <br /> I also certify that I have prepared this ppli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STA and FEDERAL law . <br /> APPLICANT'S SIGNATURE: r, ` I DATE: /'�/��/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN= C l I <br /> If APPLICANT is not the BILLGVGPARTY.proof of authorization to sign is required Ti[[e V <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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PAYWT- <br /> vet) <br /> COMMENTS: <br /> �� •�ZR�7 �,� �S oc.� 31 2005 <br /> Lim <br /> SPA N0"" MEW& <br /> HE�TN DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: /ti at T <br /> ASSIGNED TO: EMPLOYEEM DATE: WV7, <br /> Date Service Completed (if already completed): SERVICE CODE: 147 & PIE: Z Q8' <br /> Fee Amount: 2 -A�W Amount Paidall U b Payment Date `a 3 k O S <br /> Payment Type Invoice# Check# `� Received By: N G <br /> I. . . . <br />