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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busin or Prop - FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP TOR <br /> CHECK If BILLING ADDRESS❑ <br /> kaj <br /> FACILITY NAME t <br /> SITE ADDRESS J _ CL�' <br /> Street Number Directi tee Na Ci �J Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APNi# LAND USE APPLICATION# <br /> 0q) X3-0 q�_ Z( v 1-7 <br /> PHONE#2T BOS DISTRICTLOCATION E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` <br /> CHECK if BILLING ADDRESS <br /> AA'U� Mkb <br /> BUSINESS NAME PHOS - ' <br /> HOME Or MAILIN ADDRESS ,5 3� oc% (n0 Q ) � <br /> 7 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL laws. , <br /> APPLICANT'S SIGNATURE: G fl v DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: C.Q S7— A&-1 e" F,-7— RECEIVED <br /> COMMENTS: OCT 1 8 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEt4T <br /> ACCEPTED BY: U( t VEA / j4 EMPLOYEE#: Cj 3 Z( DATE: 1011C-107 <br /> ASSIGNED TO: /Ni EMPLOYEE#: 2�ro2 D DATE: U P-0,07 <br /> Date Service Completed (if already completed): SERVICE CODE: Ctk PIE: 23 U e <br /> Fee Amount: il Amount Paid y O D Payment Date 10[00-7 <br /> Payment Type t� Invoice# Check# Z3(� Received By: —Z� <br /> EHD 48-02-025 SR t?f� ( olddn'Roid) <br /> REVISED 11/17/2003 <br />