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SAN JOAQUINCOUNTY ENVIRONNIENIA nrru rn+�� ti"' •' <br /> SERVICE REQUEST <br /> Type of justness or Property FACILITY ID# SERVICE REQUEST# <br /> c:0,( <br /> OWNER/ OPERATTOR ,^ CHECK If BILLING ADDRESS❑ <br /> FACILITY NAMEQ �"I - / <br /> SITE ADDRESS T3-7��Li �N�v� \-J"N�� S ll.Q6-p'`v) q5 2xi <br /> Street Number Direction Street Name cityZI CoOe <br /> HOME or MAILING ADDRESS (If Different from Site Address)) <br /> Oel ,qL ' Street Number Street Name <br /> CITY $_T.9jE ZIP <br /> PHONE#f EXT. APN# l/L.AANLDFIUSE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT <br /> LOCA"TN CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> PHONE# Exr. <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 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 applica ' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT d EDE ws. <br /> APPLICANT'S SIGNAT\U�Rp{E/: DATE: a 0 7 <br /> PROPERTY/BUSINESS OWNE7� P TOR/ ANA ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICif/NT IS'at the Bi INN R42Tt'proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: U L74 A-C.-.(C, ( ( 10L-AJ <br /> nC>-( F—Ct:L PAYMENT <br /> COMMENTS: <br /> FEB — 1 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C�(- I v�.c EMPLOYEE#; C�1 ( DATER L f/,07 <br /> ASSIGNED TO: L l:.}{ �1 S C-(-t U �Z EMPLOYEE#: '�>(� ' DATE: 2 67 <br /> Date Service Completed (if already Completed); SERVICE CODE: SZ-3 PIE; �L^ -1 <br /> � <br /> Fee Amount: �' ��5 L,ti Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden'Rod) <br /> REVISED 11/17/2003 <br />