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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP TOR CHECK if BH LPI ADDRESS <br /> FACILITY NAmE /1 <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Z10e <br /> HONE or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE LP <br /> PHONE#t ` EXT. r APN# LAND USE APP0CATION# <br /> PHONE#2 ET• BOS DISTRICT j� LocA CODE <br /> ( ) l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME � PHONE# <br /> C I V I L NCo2• o�1 %3/'/ -3-7. <br /> HOME or MAILING ADDRESS FAx# <br /> Cm -)Ca c k cc .4 9S STATE LP <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 j <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: DATE: <br /> PROPERTY/BUSINESS OwNEIi OPERATOR/MANAGER OTHER AuTuoRmED AGENT❑ CZ-J/t <br /> If APPUCANT is not the BILGING 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. 1 <br /> TYPE OF SERVICE REQUESTED: ��'✓/e',,�J U. FJ V C l�/ ��1 l 4 �e <br /> COWAENT6:,5J- <br /> c- - 6orw•-) �c,�c� + r r�o.� y •��,' ERFCEIVED <br /> �' <br /> ;il : e7%.-.vrl NOV 1 6 2005 <br /> 3• r�ic:�.,.IJ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONME TAL <br /> ACCEPTED BY: EMPLOYEE#: / A / <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: P I E:2�V <br /> Fee Amount: Amount Paid / I Payment Date <br /> [ <br /> Payment Type Invoice# Check# Received By N <br />