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OAINJVAINU11V 1,VU1N1Y EtNVIKV1N1V1LiN1ALnhAL1H"EYA1C11V1E1N1 <br /> SERVICE REQUEST ---' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ALwe-1 C _ iQC?O <br /> OWNER/ OPERATOR G �/ r /� J 71 <br /> � �� CHECK If BILLING ADDRESS❑ <br /> FACILrrY NAME C) ( Axl <br /> SITE ADDRESS CJ` S`� L-FA 5-T /L �r G��!iC./` f S IT-c". <br /> Street Number Direction Street Name city Zip Code <br /> / HOME or MAILING ADDRESS (If Different from <br /> )Site Address) <br /> J\ '3G 1J\-A2 <br /> / - Street Number Street Name <br /> CITY -5 C���� I J STATE ZIP C`S' �1 i c <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 /> i <br /> APPLICANT'S SIGNATURE: a r DATE: O S~ O l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BILLING PARTYY,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 /> -I <br /> TYPE OF SERVICE REQUESTED: JCA <br /> RECEIVED <br /> COMMENTS: AUG 15 2008 <br /> SAN JOAOUIN COUNT`( <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: CA(—HAY EMPLOYEE M q TE: <br /> Date Service Completed (if already completed): SERVICE CODE: D P I E:� <br /> Fee Amount: "'o Amount Paid (0S V V Payment Date -yj <br /> Payment Type Invoice# Check# ZZR Received By: <br /> EHD 48-02-025 SR FOR_M(061d Rod) f <br /> REVISED 11/17/2003 <br />