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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 '5�v-o O ' y2i <br /> 'NER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 'UTY NAME K l� <br /> TE ADDRESS <br /> Street Number Direction Street Name Ci Zip Code <br /> IOME or MAILING ADDRESS (If Different from Site Address) <br /> / Street Number Street Name <br /> CITY STATE ZIP <br /> S� L�c;�J cs 26�- <br /> PHONE#1 FXT• APN# LAND USE APPLICATION# <br /> PA '94 - ( <br /> PHONE#2 EXT. BOS DISTRICT LOCAnO�DE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR //�� I CHECK if BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME /'^ � ' S '3 I ZL <br /> (�� l ) j-k rT <br /> HOME or MAILING ADDRESS n FAX# <br /> STAT ZIP C S2 <br /> CITY LI) � 0 G- <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 /> E: <br /> APPLICANT'S SIGNATURE: DAT�p(( <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0- <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: S IDI L S�� t°� t E- '-Jj PAYMENT <br /> COMMENTS: ���� ..�� �_ �- <br /> MAY 12 2008 <br /> -5 SAN JOAOUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: (�/ I f� EMPLOYEE#: C) 3 Z_( DATE: S / 0lo/ <br /> ASSIGNED TO: EMPLOYEE#: S j co b DATE: <br /> � 1 <br /> Date Service Completed (if already completed): SERVICE CODE: ,S 2L PIE: �(oC ' <br /> Fee Amo�t: �-, (v • Amount Paid 4 I q E) Payment Date (Zlo <br /> Payment Type `� Invoice# Check# , ��� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />