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�7 SAN JOAQUIN COUNTY.ENVIRONMENTAL REALTia DEPARTMEN'i" <br /> e. <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> da <br /> �c '-7 <br /> OWNER/OPERATOR <br /> AnLaLi CHECK if BILLING ADDRESS <br /> FAczm NAME C _ - L1___. <br /> SITE ADDRESS -A-IW ffy)(W M j cA5 12 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> ( 51N 5r�2- t�jl 22 <br /> PHONE#2 E)T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE# <br /> 1 <br /> HOME or WAILING ADDRESS FAX# <br /> � . ` ( & <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. E <br /> APPLICANT'S SIGNATURE: Ic DATE::y NA ., �l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C3 *t'b(C-g-nV1 <br /> If APPLICANT is not theBILLWt <br /> GPARTT,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: L4 > > �ti. t,� .�, r rcL <br /> PAYMENT <br /> COMMENTS RECEIVED <br /> NOV 3 0 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPAR'TmENr <br /> ACCEPTED BY: ✓E� �� EMPLOYEE#: 24 DATE: <br /> ASSIGNED TO: EMPLOYEE#: ( DATE: Z /( <br /> Date Service Completed (if already completed): <br /> Fee Amount: S•715� T�D Amount Paid -�JCj 00 Payment Date <br /> Payment Type G L� Invoice# Check# Received By. <br /> EHD 48-02-025 �FOhi(Go(ittt Rod) 5 <br /> REVISED 11/1712003 <br />