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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s oK ? 855 5�y� 713 <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> f D <br /> FACILITY NAME <br /> u5 ws 3G C <br /> SITE ADDRESS �� <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t <br /> (f / A(t�t 7 l0 V/N � �� S CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Zed ) <br /> HOME Or MAILING ADORES O n (AX# ) U61- <br /> 611 <br /> zeig <br /> CITY STATE ZIP u� <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: I/ DATE: 2-Z Z -6 `� <br /> O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ElOTHER AUTHORIZED AGENT Er— Zee-1", <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: l Pal RECEIVED <br /> COMMENTS: FEB 2 2 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �+ EMPLOYEE#: DATE: <br /> G <br /> ASSIGNED TO: EMPLOYEE#: �'3 7 DATE: <br /> Date Service COmplet d (if already completed): SERVICE CODE:)G ' I P I E: � �? <br /> Fee Amount: Amount Paid Payment Date r <br /> rPayment Type Invoice# Check# j"J-; Received By: <br /> EHD 48-02-025 ,SR2 CIRM(Goliien' `d) <br /> REVISED 11/17/2003 <br />