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SAN JOAQUIWUNTY ENVIRONMENTAL HEALTVEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME i� <br />FATY In <br />- <br />JUL 2 7 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />SERVICE REQUEST # <br />OWNE / ORATOR <br />/ <br />FAX # <br />CHECK If BILLING ADDRESS ❑ <br />FACILI NAME <br />CITY STATE ZIP <br />Date Service Completed (if alrea y completed): <br />SITE ADD ESS f* <br />tre nfber <br />Direction <br />/J ��� <br />< Stre a e <br />Fee Amount: �? <br />�AG <br />�7 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />5Q(%�1'i A4A' 9V;? <br />Street Name <br />CITY <br />Check #3 <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME i� <br />PHONE# EXT. <br />- <br />JUL 2 7 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />r <br />HOME or MAILING DRESS <br />FAX # <br />ASSIGNED TO: <br />( l ) <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 <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: <br />PROPERTY / BUSINESS OWNER OPERATOR / ANAGER ❑ OTHER AIITHORIZED AGENT.W,#4!2rw/ vj;g ZQX,,-ii� <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:VS %' G` <br />AYMEIS,!_� <br />COMMENTS: <br />- <br />JUL 2 7 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:&97L;2!L <br />EMPLOYEE M y <br />DATE: d C7 <br />ASSIGNED TO: <br />EMPLOYEE #: ®�� <br />DATE: <br />Date Service Completed (if alrea y completed): <br />SERVICE CODE: 3 <br />P 1 E: <br />Fee Amount: �? <br />Amount Paid <br />l t <br />Payment Date q12AI (L <br />Payment Type <br />Invoice # <br />Check #3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />