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OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O <br /> 1�8 MO 17 C2-- <br /> OWNER/OPERATOR , <br /> .C l� CHECK If BILLING ADDRESS <br /> f. <br /> FACILITY NAME �( �/f <br /> SITE ADDRESS "'2 1 fie, Q *GD <br /> Street Number Direction ! Street Name / city Zip Code <br /> HOME Or MAILING ADDRESSIfDifferent frog Site AdcJress) <br /> L 7 L►� �' /� Street Number Street Name <br /> CITY STATE ZIP <br /> �,� �- U� �-7 3-71 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 83v - 877 <br /> PHONE#2 EXT. BOS DISTRICT1[LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> —F_n ' .� —T CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME � eV PHONE# EXT. <br /> CU � ( 8 3v- 9'7- 8 <br /> HOME or MAILING ADDRES FAX# <br /> 8 �I3 <br /> CITY f�j C c 3-77 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 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 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: e4d � W DATE: C)I 3 <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: pAY M ENI <br /> COMMENTS: <br /> JAN 3 1 2007 <br /> JAN jOAQUIN <br /> ENVIRONMENTAL <br /> TM <br /> AL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 P I E: !� <br /> Fee Amount: �,Cr Amount Paid (1:s Payment Date D <br /> Payment Type Invoice# Che # (o (� Received By: N t`_ <br /> EHD 48-02-025WOI ) <br /> REVISED 11/17/2003 <br />