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SAN JOAQU- COUNTY ENVIRONMENTAL HEAL' DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />COMMENTS: l �S tnn� (-c_5 E &,o-wI( U�"� r /�(I� <br />1-(s' �T-rcJ <br />Pas S � P �Gc � <br />BUSINESS NAME <br />ACCEPTED BY: <br />PHONE# ExT' <br />EMPLOYEE #: 3 Z CSA EN,jIRON <br />OWNER/ OPERATO <br />HO or MAILING ADDRESS <br />EMPLOYEE M f _�,g C VJEA <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />vi) X71 0 <br />SITE ADDRESS <br />G1 S 2Y <br />Street Number Direction <br />Street Name xvC i CL Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />Invoice # <br />Street Number Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ' ExT• <br />APN # <br />LAND USE APPLICATION # <br />Qo, 09A <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK If BILLING ADORES! <br />� <br />COMMENTS: l �S tnn� (-c_5 E &,o-wI( U�"� r /�(I� <br />1-(s' �T-rcJ <br />Pas S � P �Gc � <br />BUSINESS NAME <br />ACCEPTED BY: <br />PHONE# ExT' <br />EMPLOYEE #: 3 Z CSA EN,jIRON <br />ASSIGNED TO: �° 47F_ I,' <br />HO or MAILING ADDRESS <br />EMPLOYEE M f _�,g C VJEA <br />FAx # <br />Date Service Completed (if already completed): <br />vi) X71 0 <br />CITY <br />STATEr 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 <br />COUNTY Ordinance Codes, Standards, STATjand <br />APPLICANT'S SIGNATURE: <br />the work to be pe rmed q1 be done in accordance with all SAN JOAQUIN <br />laws. cU�-T"-1i,c- � ` <br />DATE: � — /1— V's <br />t <br />PROPERTY/ BUSINESS OWNER 11 TOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not to 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 ENVIRONMENTL HEALTH DEPARTMENT as soon as it is a`� <br />available and at the same time it is <br />provided to me or my representative.,( L'Tf ' �; (�( /, 1 1„x, L ; t �-� ., r /- , i -v /' �1 ) <br />TYPE OF SERVICE REQUESTED: (S'1- <br />j� .t�-�12� (�t�L� <br />COMMENTS: l �S tnn� (-c_5 E &,o-wI( U�"� r /�(I� <br />1-(s' �T-rcJ <br />Pas S � P �Gc � <br />f -r te- � <br />t� �57WYY <br />REC,VC�CQ I <br />g 2005 <br />AUG <br />INV <br />ACCEPTED BY: <br />EMPLOYEE #: 3 Z CSA EN,jIRON <br />ASSIGNED TO: �° 47F_ I,' <br />EMPLOYEE M f _�,g C VJEA <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:/ g <br />P i E: 3 C) <br />Fee Amount• , ] 5,(-, G' <br />Amount Paid ��-, c� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # / o � <br />Received By <br />H <br />