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SAN JOAQUINTY ENVIRONMENTAL HEALTH D) TMENT <br /> WN SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QA,5 -'Y-FAn0J . ::[ 5 )�M C16197 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> ce, T U 3 <br /> FACILITY NAME ( � <br /> SITE ADDRESS �J ,/ <br /> aIrect Q�VV-`e- fL� <br /> 3 Street Number Direction � reef Name Ci� 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 /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS. <br /> BUSINESS NAME PHONE# ExT' <br /> yob I (� )-3 y <br /> HOME Or MAILING AD S1i <br /> S FAX# <br /> ivt (' ) 02( 01 <br /> CITY C STATE /1 ZIP qS <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized argent of same, <br /> acknowledge that all site and/or project specific ENviRoNmENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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. ` L <br /> APPLICANT'S SIGNATURE:111, [t i la u L ��E.t d �`% DATE:y �11�_� �G <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT LT ��� lT �G GLI ki'u 6 4w, <br /> If APPLICANT is not theB1LL12VGPAx71 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 t�pYMENT <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmen ECEIVED <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. MAR 2 3 2006 <br /> TYPE OF SERVICE REQUESTED: SAN OAQUIN COUNT <br /> 1' _ 1p� �p _H <br /> ENVIRONMENTAL <br /> COMMENTS'. C" ��� j SS I K,S Cx V "� � l U - < <� 'S �1+� " OACS H DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: Z <br /> Fee Amount: Amount.Paid f*.�;)-7 Cts Payment Date 3 Z3�O /o <br /> Payment Type Invoice# Check# 20 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />