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SAN JOAQUIN f"OUNTY ENVIRONMENTAL HEALTH TIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS �,5 5 ///J� C' L^, �a <br /> Sheet Number Direction Street Name C ` 27 Code <br /> HOME or MAILING <br /> /ADDRESS (If Different from Site Address) C` cJ,� G"2 , <br /> (� J /�.'/� Street Nvmbcr - street Name <br /> CI <br /> N i� F/GLG Sw//, ZIP��/ G' <br /> 7— <br /> PHONE#1 ' APN# LAND Use APPLICATION# <br /> ( ) - 3 0 — Z Z ?('� 05— 1i9 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORd CHECK if BILLNJG ADDRESExS <br /> BUSINESS NAME PHONE# T' <br /> Ci✓� .vc�{e , ani ci3�`1 - 75' <br /> q3%— 2 373 <br /> HOME or MAILING ADDRESS Fes# <br /> 5�� !�r_( /�7_nG/ f (��) <br /> ` /")LL f/ AV <br /> CITY e5 CcN- hy) b 9 / STATE ZIP <br /> BMI,ING ACKNOWLEDGEME : 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. 3 <br /> I also certify that I have prepared this application and that theT, ::— <br /> rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST d FEDERAL la <br /> APPLICANT'S SIGNATURE: - DATE: <br /> ( <br /> PROPERTY/BUsrNESs OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT Iii L t <br /> IfAPPLICANTis not the BLLLLNGPABTY proofofauthorization 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 environmentaUsite 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: /Q�vz Sd{ / •�[l : L✓ � '. RECE�'✓ED <br /> COMMENTS: �/' / O .-r / „ /�/� O <br /> L.tY / '/lff V NOV 1 E 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �' L_T L•�i KI--�Q EMPLOYEE#: ,3 z I <br /> S I L $ DATE: ' G <br /> TE:EMPLOYEE#: � cASSIGNEDTO: C(- t :� <br /> Date Service Completed (if already completed): SERVICE CODE: Sa Z PIE: L t_ ��I <br /> Fee Amount: $J I�� L.v Amount Paid 8•� D Payment Date I �� <br /> Payment Type ✓ Invoice# Check# 3 U Received By: -11 <br />