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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> OWNER/OPERATOR 7 �rvs CHECK If BILLING ADDRESSED <br /> FAciuTY NAME ,,!' t <br /> SITE ADDRESS �'O �YiZZ� t""Lk(� ��Gt—�� Lr AC/.J <br /> Street Number Direction S[reet Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 420e f,4PI"46 <br /> Street Number Street Name <br /> ZIP n��5-6 <br /> CITY ,f/,�] GJDD�/� STATE C4 `� <br /> PHONE#1 ` EXT. APN}f LAND USE APPLICATION# ,� <br /> X0777 00 " 3� �,4 - U S- 778 his <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) IJJI <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEP <br /> %v EXT. <br /> Dl � c Niup-pW NZaY <br /> HOME Or MAILING ADDRESS FAX# <br /> XX 218O ( ) 33�-O7Z3 <br /> CITY l 0 STATE C^ ZIP C,52fL/ <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance w SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE DERAL laws. // <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER E01 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 EPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. - ` - EN <br /> L <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: OCT � O 2006 <br /> 3 <br /> Nl.f- v SAN OAQ�tN COON <br /> ENVIRONMENTAL <br /> HEALTH OEPARTNiE <br /> ACCEPTED BY: t�L( i, 'rt e,� EMPLOYEE#:11 DATE: <br /> ASSIGNED TO: t C' 40 <br /> EMPLOYEE#: �G� DATE: loll <br /> 0/b <br /> v <br /> Date Service Complete if already completed): J SERVICE CODE: P I E: <br /> Fee Amount: . .� Amount Paid 'k=;Le'�7 0 Payment Date l p b <br /> Payment Type ,� Invoice # Check# �� <br /> C7a io 3`j2Received By: <br /> ) <br /> EHD 48-02-025 O r� � ` �� SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />