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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST db <br /> Type f Business ff Property FACILITY ID# SERVICE REQUEST# <br /> OWN0/OPERATOI L <br /> /1lJ CHECK If BILLING ADDRESS❑ <br /> 4D ���o rn a�AfV <br /> FACILITY NAME <br /> SITE ADDRESS weet 1�a-- <br /> 14y� ' <br /> Street Number Direction 71 r VlC/i I /+J Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number reet Nam6 ! <br /> CITY C�j ST E ZIP <br /> Q PHHOIQ�/ EXT• 7NE#1N# LAND USE APPLICATION# <br /> PHONE#2 r EXT. BOIS DISTRICT LOCATION CODE <br /> J�b�- 9- 2- <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEP, &ea PH,-bl ONE# '] Err. <br /> "I' I <br /> HOME Or MAILING ADD ESS (� ) <br /> CITY STATE ZIP <br /> 5a-� <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 appli *on 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. fj 0i <br /> APPLICANT'S SIGNATURE: `I (J�/ DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �fU <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: U S T- "1 f—O o F �(n/IEN- <br /> COMMENTS: RECE <br /> SEP 2 4 2007 <br /> SAN 3OAQUIN COUNTY <br /> EALTH DEPARTMENT <br /> ACCEPTED BY: U E/ EMPLOYEE#: O 32-�' DATE: C?7 Z41f <br /> ASSIGNED TO: V p-J FL Lt-,5- EMPLOYEE#: ?3 1 7 1 DATE 17 Z07 <br /> Date Service Completed (if already completed): SERVICE CODE: r qr P I E: 23U <br /> Fee Amount: WGzq o J Amount Paid Payment Date 4 �� <br /> Payment Type V Invoice# Check# a Received By: <br /> EHD 48-02-025 SFSQ(NF,(r?old@n F:od)` <br /> REVISED 11/17/2003 <br />