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SAN,IOAQUOOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS D <br /> FACILITY NAME / <br /> SITE ADDRESS uy� b <br /> Street umber Dition g El==C <br /> 9 S <br /> Street Name Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 17 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> �� <br /> 0" CHECK CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY , ^ ` STAT ;1 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 ENVIRONMENTAL HEAL'rll DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 Ory illatIc-e COC/es.Slanc/ards, S'I, "fG and FEDERAL. laws. <br /> .APPLICAN'T'S SIGNATURE: <br /> DATE: <br /> PRoI>r:1Z /131;SINliss( WNER❑ OPI?RATOlt/MANAGER ❑ O•rnER AUTHORIZED AGEN'T'( O L-Ce �/�A <br /> lI'APPLWA T is not the BILLING PART),proof 0j'uuthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 ENVIRONMI?N"I'AI, HI'_AI.I-II DIiPAIt"I'MI-N"I'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 _( T �E" t;fC t—T— pAYMEN <br /> COMMENTS: R - T7[DT- <br /> JUN <br /> �0 5 2007 IF � <br /> SAN JOAQUIN COUNTY JUN 0 5 2007 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT LIV{ HEALTH <br /> ACCEPTED BY: �t_t ��t _� ,( EMPLOYEE#: �� , <br /> �'C Z� 01 ASSIGNED TO: � <br /> r�✓.4 t D i- EMPLOYEE#: DATE: <br /> /S.. O-7 <br /> Date Service Completed (if already completed): SERVICE CODE: (C2,�� P/E:c�3 C)IPFee Amount: 5. Amount Paid 'I$gOS Payment Date <br /> Payment Type Invoice# Check# _:?-7 Received By: <br /> EHD \ � <br /> REVISSEDED111/11/17/2003 SR FORM(Golden Rod) <br />