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COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of usiness or Pronerty FACILITY ID# SERVICE REQUEST# <br /> OWNER VOPERATOR /1: / _ <br /> �+a i7 <br /> CHECK If BILLING ADDRESS❑ <br /> _ (� V �,t <br /> FACILITY NAME <br /> SITE ADDRESS ILA <br /> / j( q N)� <br /> Street umber Dir ior( Stre4N. . Ci i 2i Code <br /> E Or MNG AD ESS (If Different from Site Address) (//L�J �a�,� <br /> Street Number Street <br /> CITY Al 14041--1 LY STATE ZIP %O 75 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> vo ) �/,56 0 /SID-3 0 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 46px�f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ( hm - e <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> 2 <br /> HOME or MAILING AD ESS FAX#' <br /> ,Z";ffZ kri rwla� 4�) C7-6)1 <br /> 3 �- <br /> CITY STATE ZIP <br /> I <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 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,STA a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 6b DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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: T A9--sc7-,�' eF—c r RECEIVED <br /> COMMENTS: AUG 7 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L-Ll�t �/� it EMPLOYEE#: C)3 2 DATE: <br /> ASSIGNED TO: t EMPLOYEE#: O-C,? DATE: 62/4 0 7 <br /> Date Service Completed (if already completed): SERVICE CODE: 1 50 P/E: 230S— <br /> Fee Amount: p Amount Paid t T. Payment Date <br /> Payment Type L/�� t fi Invoice# Check# �a( kc, Received By: <br /> EHD 48-02-025 C� ! ✓ r 5R f4R)Yt(. ol'den i7oif) 5 <br /> REVISED 11/17/2003 <br />