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05-22-06 02 Wpm From-TAIT ENVIROL 714-560-8237 � T-666 P.02/06 F-995 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNE / RATOR CHECK If BILLING ADDRESS <br /> F NAME <br /> AgLITY <br /> SITE ADDRESS <br /> scno< M4.1, s yJv' dO,r nt Nahm c• <br /> HOME or MAILING ADDRESS (If Dlffarent from Site Address) <br /> Steak Number L Street Nana <br /> CITY STATE ZIR <br /> FacT. APN# LAND USE APRUCAnoN <br /> PHONE#1 E <br /> ( ) <br /> PHONE#2 Ex►• SOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE RE',QUESTOR <br /> RE ESTOR CHECKif BILLING ADDRESS <br /> .•�=�=•�- • PHONE# ice 1 <br /> SuslNEss NAME a t11' <br /> HOME or MAI NG ADDSg�ss FAx# <br /> IiITY �. STATE 466- ZIP <br /> 'BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONLIPWAL 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. <br /> APPLICANT'S SIGNATURE: DATE;Z'KS&&d <br /> PROPERTY/BUSINRSsOWNER OPelwroR/MANAGER Q 0THCRAuTHORt29DAGENT® <br /> IfAPPLIC.AhFT is nor the ttn.T„INC,PAR Tr 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, gcotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIEPARTMENr as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYM <br /> TYPE OF SERVICE REQUESTED; 0 CST_ FiECE)VED <br /> COMMENTS: JUL 11 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> n 17 <br /> ACCEPTED BY:U EMPLOYEE#: DATE: <br /> ASSIGNED TO: —^OVA <br /> EMPLOYEE#: f S DATE: <br /> Date Service Completed (if already lornpleledv SERVICE CODE: IPIE: 2- <br /> Fe®Amount: Amount Paid Payment pate � �k <br /> Payment Type ✓ Invoice# Check# '4� 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />