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SAN JOAQUIIOOUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESSRti-CceCAtLA(aM7V <br /> FACILITY NAME <br /> SITE ADDRESSy.� q <br /> Street Number Direction Street Name Ci 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (,,753 (oql—G.31V <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ..... C (Ste� ���1 �t LL_tm N ECK if BILLING ADDRESS <br /> �T✓ `i(�J��(J/`J �{- EXT. <br /> BUSINESS NAME�IrPHONE v` •{'1._.�.�`A <br /> HOME or MAILING D RESS Y1 FAX# <br /> n 469 ) 213 b b'�- 4 <br /> CITY ( , STATE (! zip 9T11-1—T 1/� <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: 4LIt td� , .�C.t a��l`.t,�' DATE: /t `F' y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT P <br /> If APPLICANT is not the BILLING PARTY:proof of authorization to sign is required 14� 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: )AMAEN <br /> p �, �p i^,. �q� ( _ ED <br /> COMMENTS: I' OU-S�1� V"1.� �� d� C�� �W" 011 & r`e,laj I' eCXlJ-fsr, <br /> ��J// Mar 0 4 2006 <br /> SAN JOAQU I COUNTY <br /> ENVIRON ENTAL <br /> HFALTH DE F ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: O DATE: <br /> ASSIGNED TO: EMPLOYEE#: J� 3 DATE: <br /> 6,44 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid ( 0 Payment Date 57't(o b <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />