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SAN JOAQOUNTY ENVIRONMENTAL HE <br />ALTPARTNIENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />G P6 l M 1 tJ I k 7- <br />CITY STATE ZIP 77�1 <br />� z <br />a s a6j <br />OWNER / OPERATOR Mgs ��"� Z�1 c <br />, <br />Px4act._ <br />CHECK if BILLING ADDRESS ❑ <br />kAdcsNt" soDt l c Rupiv-Ae <br />FACILITY NAME I � � tr \a � � Q P � ^ � ' r <br />, : _ \ 0Lyyt-e <br />L I (SZ v ve- Af E, A -s <br />SITE ADDRESS�� <br />DATE. <br />� th L.h e- <br />! Z 6 <br />9tS�Z <br />i) \ Street Number <br />Direction <br />Street <br />Name <br />Amount Paid g QD <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # r) S <br />Received By:� <br />�� el.J ✓� CT' <br />Street Number <br />Street Name <br />Sn <br />Zip ' <br />PHONE #1 EXT- <br />APN # <br />LAND USE APPLICATION # <br />(20-o q I4 - SS'i:-� <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP 77�1 <br />BILLING ACKNO`VLEDGEMENT: 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 applica ' and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT a�o FEDERAL law . <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS O WNEI ,--- 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: <br />COMMENTS: <br />NO V 2 7 2007 <br />SAN JOAQUIN COUNT, <br />ENVIRONMENT <br />AL <br />HEALil- DEPART NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE. <br />ASSIGNED TO: " i <br />EMPLOYEE �-y1t" - <br />rE: <br />Date Service Completed (if already completed) <br />SERVICE CODE - to o <br />I __Ej <br />PIE: <br />Fee Amount: <br />Amount Paid g QD <br />Payment Date <br />Payment Type ✓ <br />Invoice # <br />Check # r) S <br />Received By:� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />