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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST db <br /> Ty p f Business or ro erty FACILITY ID# SERVICE REQUEST# <br /> OWN RI OPERATORC„n m / / f n <br /> ��/ l C K CHECK if BILLING ADDRESS <br /> 1P5 6 <br /> FACILITY NAME `/ &- AI,-7� t Y <br /> SITE ADDRESS `�^(/v%�)(/ l./� ']`/ <br /> Street�mber �Diredio t n/e "' Ci � Zi2 Code <br /> HOME or MAILING ADDRESS (If Di ffe �tQfrom Site Address) /!) /,,y/ .�(//)/yl�' <br /> K m Oet Number v ' r S tThafrR ' " `i <br /> CITY I 4[ TATE Zn J <br /> PHON f /EXT. APN# '/ ,/ LAND USE APPLICATION# •/7 <br /> OT � Pyt�� d f _I o�0`I', <br /> PHONE#2 ET. BOS DISTRICT v LOCATION CODE / <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , , 1/ y ' ; 'I. . <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ^„„ !� PHo07N,E ^ / /_33 f <br /> HOME Or MAILIN ADDRESS — G( �/�, FAX 51) 'l"(fC//—(�(/G��lJF <br /> CITY GnCJ�• FV�//'v STATE 4//lzziip <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE aF DERAL laws. /^ ' <br /> APPLICANT'S SIGNATURE: P" /&L DA q4 <br /> n l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT V <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is require 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 /> 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: PAYMENT <br /> COMMENTS: <br /> MAY 0 4 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: sr DATE: q It <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid a 5 Pay t Date 5 0 <br /> Payment Type t/ Invoice# Check# "� 3 Received By: <br /> EHD 48-02-025 .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />