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FEB/07/2008/THU 05: 12 PPS 1M ign Group FAX No. 916 771 X55 P. 004 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL,TJVALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or roperty FACILITY ID# SERVICE REQUEST# <br /> ,6 ---CI r 3 <br /> OWNrtR/OPE R `` CHECK If B} LING ADD�E3813 <br /> .I l <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 9veetNumbar Dimetion t� `^ et a ZI C <br /> HOME or MAILIN DDRESS (I Iff rent Sfrom Site Address) <br /> N..bar treet Na <br /> CITY <br /> STAT ZIP net <br /> tI <br /> P QNE#'� <br /> W. APN# LAND USM APPLICATION# `'J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRAC'T'OR/SERVICE REQUESTOR <br /> R50UESTOR CHECK if BI 2 AD Ess❑ <br /> NE# lexr. <br /> BUSINESS NAME P <br /> ; l <br /> HOME or MAILING ADDRE33 F # <br /> ZIP ( �o ) <br /> CITY ♦ 1 I STATE zip 1 <br /> BILLING A(:KNO'WLEDGEMENT: I, the undersigned property or business owner, operator or outho ized at of same, <br /> acknowledge that all site and/or project specific EN"XONMENTAL HEALTH DEPARTt,ENT hourly charges assoc ated with is 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 ithI•!JO IN <br /> COUNTY Ordinance Codes,Standard' STATE and FEDERA <br /> ws. <br /> APPLICANT'S SIGNATURE: f DATE: <br /> PROPERTY/BUSINESS OwNtR❑ OPEPLATOR/NIANAG OTtum AUTHORtzrai AGENT <br /> 1f APPLICANT is not the BILLING P pr of of at thorization to sign is required T N <br /> AUTHORIZATION TO UXLE SE INFORM TION: applicable,I,the owner or operator of the property ocate e <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sir assess �i\ <br /> information to the SAN JOAQUIN COUNTY ENVIkONMENTAL HEALTH)DEPAkTMENT as spun as It IS availay� arla h a a time <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: d- a 7 LO <br /> UNN <br /> COMMENTS: / / JOAaUIPI t4 AL <br /> Ham``JOW.t PFFD TMEt�T <br /> ACCEPTED BY: ENIPLOYFE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICECODE: PIE- <br /> Fee Amount: Amount Paid 9 Payment Date ? 01b <br /> Payment Type Invoice# Check# D3 Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/ZO03 <br />