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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />7 <br />FACILITY ID # <br />SERVICE REQUEST # <br />C <br />ACCEPTED BY: 1 <br />�� C (L' & (tvr`� <br />C< c J <br />S i� )o <br />OWNER OPERATOR <br />ExT' <br />-z <br />HOME Or MAILING ADDRESS <br />FAX # <br />CHECK If BILLING ADDRESS <br />L'ot vi'r r- 'N z C' � <br />L , <br />(2001 ) <br />FACILrrY NAME <br />4v -c -o -}A c8Z(oCl S <br />CITY �-,VL\Li.;— <br />STATE C <br />SITE ADDRESS <br />,I� ��a`i <br />c h ci j Z `' —5 <br />Street Number Direction <br />Street Name <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Check # 70 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( )041) <br />ISS - b20-& <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />(c"i) 193- 792 <br />(f' C L21 - <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />7 <br />CHECK If BILLING ADDRESS <br />L✓�,,.�a�N�� '1 i <br />PAYME <br />RECEIVED <br />MAR 15 2007 <br />SAN JOAgUIN C <br />ACCEPTED BY: 1 <br />�� C (L' & (tvr`� <br />BUSINESS NAME <br />EMPLOYEE #: <br />PHONE # <br />'7'J4 -L) <br />ExT' <br />-z <br />HOME Or MAILING ADDRESS <br />FAX # <br />-,31 <br />j-jJ S C3.�" <br />Date Service Completed (if already completed): <br />(2001 ) <br />GcC `L2 i <br />CITY �-,VL\Li.;— <br />STATE C <br />ZIP eSZ. <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. <br />APPLICANT'S SIGNATURE: ' L- :- ! ; ` '.!. DATE: <br />PROPERTY/ BUSINESS OWNER Er OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: C p S (t ` %7 0 ti — A-1 <br />7 <br />COMMENTS: <br />PAYME <br />RECEIVED <br />MAR 15 2007 <br />SAN JOAgUIN C <br />ACCEPTED BY: 1 <br />�� C (L' & (tvr`� <br />EMPLOYEE #: <br />c 3 ? / HEALTH <br />4 TM J(5 [:7 <br />ASSIGNED TO: C> AJ F1 Gt- <br />EMPLOYEE M <br />-,31 <br />DATE: ? L< �O <br />Date Service Completed (if already completed): <br />SERVICE CODE: O <br />P! E: 2 <br />Fee Amount: Cj �. ,_,L <br />Amount Paid <br />9� <br />Payment Date D <br />Payment Type <br />Invoice # <br />1 <br />Check # 70 <br />Received By: <br />EHD 48-02-025 SR FbRM (Golden'Rod) <br />REVISED 11/17/2003 <br />