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SAN JOAQUI, —7UNTY ENVIRONMENTAL HEALT- DEPARTMENT <br /> SERVICE REQUEST <br /> Type o siness or op rt y FACILITY ID# SERVICE REQUEST# <br /> F a o o o 3 co 5 r-�,D o 3X73 <br /> OWNER OPERATOR 6,0 <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Oau—h ' <br /> SITE ADDRESS <br /> 107S et Number 'rection ka" eel e e <br /> HOME or MAILING A DR SS (If Different from Site Address) <br /> Street Number ame <br /> CITY STATE zip <br /> PHONE#1 /`1/� EXT. APN# LAND USE APPLICATION# <br /> Q(P-'h, 1 / <br /> EXT. BOS DISTRICT LOCATION CODE <br /> U CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO ` CHECK if BILLING ADDRESS <br /> BUSINESS NAME n �. PHON T7 <br /> HOME or MAILING ADDRESS IV <br /> FAX# <br /> CITY STAT zip <br /> BILLING ACKNOWLE MENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andJor 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 ATk and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN <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 /> ni� I ENT <br /> TYPE OF SERVICE REQUESTED: C.L.S I �FTK C` t• i CE <br /> COMMENTS: <br /> AR 2 4 2004 <br /> NOAQUIN CO <br /> HEAL TI De gl3NME� <br /> ACCEPTED BY: CJL.t l /I EMPLOYEE#: �i�j Z / DATE: j 12-Ci Oj <br /> ASSIGNED TO: /C) LA'C E- EMPLOYEE#: F-3 / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �,V� <br /> Fee Amount: �2--7 5,c U Amount Paid Payment Date 2 16 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden ) <br /> REVISED 11/17/2003 <br />