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JAN JOAQUIN (AUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c . SERVICE REQUEST# <br /> P- 15 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> t� pp C� <br /> f CA <br /> SITEADDRESS `TC�0 \Oe-91k LQ�¢- qS�\D <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Q\\ Street Number Street Name <br /> CIo \ z STATE ZIP 9 5 V <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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. �T <br /> APPLICANT'S SIGNATURE: k• k PA e 6. dpt�= DATE: 1— <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/AIANAGER ❑. OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED - <br /> COMMENTS: MAR 16 Z009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> In <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 3 //„ <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: v <br /> Fee Amount: 5 Amount Paid s Payment Date 3 w U 9 <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 4 3 �2XORM Golden Rodj�-" <br /> REVISED 11/17/2003 <br /> 1 <br />