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JAN JOAQUINCOUNTY ENVV1KUN1vLPA41AJ- <br /> SERVICE <br /> LSERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 , ,� �i / <br /> OWNER OPERATOR CHECK if BILLINGADDRESS <br /> L <br /> FACILITY NAME <br /> SITE ADDRESS �� a� C,n.� � <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from SlIq Address) <br /> Street Number Street Name <br /> CITY,1,y.,f,_ r„ L„ - Q, ,^ STATE ZIP <br /> PHONE#1 ' fir' APN# LAND USE APPLICATION# c� <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE:J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE If Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 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,Standar STATE and FEDERAL law ////? <br /> APPLICANT'S SIGNATURE: ( jJ1 �J/X / DATE: �l% D <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I PPLICA 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 environmentaUsite 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: N S I-L AJ — /J Eeti CEJ ti/ <br /> COMMENTS: RECE VED <br /> J(/N 19 <br /> 2007 <br /> 04QLI CO <br /> ACCEPTED BY: �) C V� r r� EMPLOYEE#: V��HYIPq/fT '� DATE: �� �� <br /> ASSIGNEDTO: y EMPLOYEE#: (�J�� DATE: (p/07 <br /> Date Service Completed (if already completed): SERVICE CODE: ��, P I E: �L�,®L <br /> Fee Amount: - lt'$. r/Zj Amount Paid a Payment Date (11 ' <br /> Payment Type Invoice# Check# - - Received By: <br /> EHD 48-02-025 '.,SSR 96 (holden Rod) ' <br /> REVISED 11/17/2003 <br />