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SAN JOAQUII' "7UNTY ENVIRONMENTAL HEALTH r ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OV`�t2/�1M1 NT - hLkt4tG►PALrr DDa <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> G %-r vF L-ab <br /> FAdUiY NAME <br /> SITE ADDRESS ( �D . A*, L�111E L.pD GL�Z4 v <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 0 • Street Number Street Name <br /> CITY � k STATE Zip <br /> Sz 1 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> Zp`1►3 3 3- Lv70ly - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH E# EXT. <br /> P P� lamxvlc.,e Mi/ 3-k'a -Slo�3 <br /> HOME or IMAILIF p A ESaU,^� ( /j ) ���— <br /> �C,Tywe--,- <br /> �� �,^r ►C� TATE (O 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 <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: Z S d <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER 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: G. <br /> COMMENTS: 7a � t5-44r= L Vl l t_- ��v< </V .art? TO r <br /> AUG 1 7 2006 <br /> SAN JOAQUIN CO <br /> ,JNV1RQAJ1A—_UNTy <br /> { <br /> ACCEPTED BY: EMPLOYEE#: DATE: O1 I RTMENT <br /> ASSIGNED TO: EMPLOYEE#: MZ1 <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Q� Amount Paid Payment Date (lo <br /> Payment Type vv�� S Invoice# Check# Received By: 62�y <br /> EHD 48-02-025 a 1 O D 8'(�l v / F RM(Golden Rod) <br /> REVISED 11/17/2003 <br />