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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T tj DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 15J 5 r <br /> OW ER 1 OPERATOR <br /> rilC CHECK If BILLING ADDRESS <br /> FACILrrY NAME <br /> SITE ADDRESS E , Fr�C �� �� C�J CA 115'3 3 � <br /> /39 Street Number Dlreclion Street Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5-41G o GA1/CV <br /> • Street Number Street Name <br /> C STATE ZIP <br /> `rY 3 �a h c Ac{s 15� <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> 62-5-) S 3 2 01 03b 1,f{ <br /> PHONE#2 EXT, BOS DISTRICT y LOCAna CeE <br /> 45-0) 7 9 7I S C O 0if <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINEss NAME PHONE# <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 FI;DvRA laws. <br /> APPLICANT'S SIGNATURE: it:Le DATE: //- — 7 o <br /> 1POPERTY J BUSINESS OWNER❑ OPERATOR 1 MANAGER C OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: % a PAYMENT <br /> COMMENTS: <br /> NOV 2 7 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPAFITMENT <br /> ACCEPTED BY: ��[ EMPL❑YEE#: 597-1q DATE: 11 17— <br /> ASSIGNED <br /> ZASSIGNED TO: [�a� EMPLOYEE#: zj1Zj9 DATE: {f 1271& <br /> Date Service Completed (if already completed): SERVICE CODE: �� P i E: Y4 dy <br /> Fee Amount: ZS co Amount Paid $ S J)'� Payment Data `� �to [,Q <br /> Payment Type Invoice Check# 1-71-3 Received By: <br /> EriD 48-02-025 <br /> REVISED 11/1712003 <br />