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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST • <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERA <br /> TQR <br /> ' I' <br /> CHECKIf BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2 i/j y5 / <br /> �SJtree"0 N'umber�JDlrect/(oVn ,`Street Nafne t / Ci ZiC @yode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> oop 333 -oLq- z. 0 (35-1 (0 D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /'// //nd /'Q M � �j CHECK if BILLING ADDRESS�' <br /> BUSINESS NAME C� I.Lfi- / / `/ /,( C• PHONE EXT. <br /> /fit° a0t07-$ <br /> HOME or MAILINGAD RESS FAX# <br /> c<?S5- JV110a_11-) tOr- ) lQl - <br /> CITY Q �.../J /On 5�OS STATE ZIP <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.and FEDERAL laws. //�90 _Q/ <br /> APPLICANT'S SIGNATURE: Z DATE' jo—/a.- OG <br /> PRROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT 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 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: S I YMENT <br /> COMMENTS: U RE <br /> OCT 2 3 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: /� O <br /> ASSIGNEDTO: J(,� EMPLOYEE#: t DATE: t <br /> Date Service Completed (if ady Completed): 0 SERVICE CODE: _ J <br /> Fee Amount: 2g Amount Paid $�� /) � Payment Date �Ql C � l <br /> Payment Type Invoice# Check# ! 7 Received By: 16 <br /> EHD 5 -$R FORM(Golden Rod) <br /> REVISEDSED 111 11/17/2003 v \\ <br />