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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> • SERVICE REQUEST 0 <br /> Type of Business(P pperty FACILITY ID# SERVICE REQUEST# <br /> l rel S2co zf q 7-o a <br /> OWNER/ OPERA y n / <br /> /I p /G CHECK If BILLING ADDRESS <br /> F 1 A � !C <br /> 1 <br /> SITE ��16' <br /> treet Number I Direction ame '1��. r" ZiuCo`de <br /> HOME M <br /> ILING ADDRESS (If Different fro&n Site Address)) <br /> Street Number V' St et <br /> CITY $ TE ZIP <br /> 4�DW q. -7 <br /> PHONE#t EXT PN#ALAND USE APPLICATION# <br /> 'PH #2 <br /> %n �/J ^/EXT. BOS DISTRICT LOCATION COD <br /> E <br /> Y' 1 CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE ) / 6,,�,/EXT. <br /> HOME Or MAILING ADDRESS ^� � � % � �A�, T' FAX# <br /> CITY ( Lzip <br /> BILLING ACKNOWLE GEMENT: 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 s identified on this form <br /> I also certify that I have prepared this a lic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TAF and FEDE laws r <br /> APPLICANT'S SIGNATURE: / Lt DATE: <br /> PROPERTY/BUSINESS OWNER❑ '.--OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 /> TYPE OF SERVICE REQUESTED: PAYMF-N f <br /> COMMENTS: <br /> N�� 7 2005 <br /> PIN�OAOUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /y EMPLOYEE#: DATE: �� S <br /> ASSIGNED TO: ! EMPLOYEE#:3rU v DATE: /( <br /> Date Service Completed (if already completed): SERVICE CODE: r ! PIE: 1-3% 8 <br /> Fee Amount: Amount Paid q nO Payment Date <br /> Payment Type Invoice# Check# O2 Received By: <br /> r .f'.14 l�'�y,�e/°,/';��y�+[ 'F�yR}'d Iy'���..+�W-nQ Y r}�" t 4 'j� .. .. ... .. .•l.Y.". <br /> -I�'�i'x!.i.`'.7(u,4y..��fpS'RIX1.[ti.,�:. ... t Y:e',2 �,r,e.P .k_P.. .,. • r..... .. .. - .. <br />