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Jul 07 06 09:46a Jeffrey C. Henley 714-739-1499 p.12 <br />SAN JOAQUO COUNTY ENVIRONMENTAL HEALTSEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />prat <br />FACILITY ID # <br />oo(7 �� � <br />SERVICE REEIQUEST # <br />�� 1 � <br />OWNER / OPERATOR <br />CHEcx if BILLING ADDRESS❑ <br />FACILITY NAME <br />ASSIGNED 70: <br />SITE ADDRESS <br />Street Numher <br />D'rection <br />Street Name <br />city <br />Mp Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PH0NE#1 Exr. <br />1 ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />{ ) <br />I Received By: / <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK N BILLING ADDRESSEY <br />-�'t .-T�. �� 'G '�--tZ�j ` l'�."3or�.�Qs' Com- ^�►� <br />BUSINESS NAME PHONE# Ems' <br />L 10 V Nc- <br />HOME or MAILING ADDRESS FAX # <br />1 1 to)L — -iz4 <br />CITY STATE CC,, zip <br />BILLING ACKNOWLEMEMENT: 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 1 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 ERAL laws. <br />APPLICANT'S SIGNATURE DATES: /7 1C, IQ <br />PROPERTY/ BUSINESS OWNER❑ OP GER 13 07HERAOTHORuEDAGENT <br />ES <br />If APPLICANT is not the BILLINGPARTY 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 ittiiss ava„ilat"rV at the same time it is <br />provided to me or my representative. 11VV t� <br />TYPE OF SERVICE REQUESTED: 55— <br />CoMMENTS: <br />JUS <br />SAN JOAQUIN COUNTY <br />NEgLTH DEPASTtAp T <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 7 1010 <br />ASSIGNED 70: <br />EMPLOYEE #: C> `7 <br />DATE: <br />Dat6 $Crvica Completed (if already comp d)' <br />SERVICE CQDE: <br />PIE: <br />Fee Amount: �;� <br />Amount Paid <br />q 9 <br />Payment Date 1 <br />Payment Type �/ <br />Invoice # <br />Check # SM <br />I Received By: / <br />END 48-02-026Iod) <br />REVISED 1 111 7/200 3 <br />Y-1�L I 11 c.1.1i 6 <br />r r� <br />