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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RfAa" t i 'X0 0 11 IM <br /> OWNER/_OPF.�RATOR fC� / <br /> P R (/L� ! ,�.��'n,`i��lLJr �j`G CHECK If BILLING ADDRESsa <br /> FACILITY NAME IJP <br /> SITE5s� Y?70", 99 9a/ 7 tf I`? /I / CA 9 ° <br /> J Street Number Direction Sire¢l Name Ci 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 /> I I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> G CHECK It 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicati an that the work to be per will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S(andards,STATE an E <br /> APPLICANT'S SIGNATURE, DATE: <br /> PROPERTY/BUSINESS OWNER I OPE TR/MXN—AGER 0 HHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLIN PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INF RMATION: 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 t0 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: OK :r a rt ` <br /> COMMENTS: RECEIVED <br /> DEC - 2 2011 <br /> MAN.OAQUIN COUNTY <br /> EWRONYENrAL <br /> �a HEALTr FM <br /> ACCEPTED BY: L 1 O..1 • .O EMPLOYEE#: S I DATE: 2 L <br /> ASSIGNED TO: V EMPLOYEE#: /j � DATE: t -Z I <br /> Date Service Completed (if already completed): SERVICE CODE: h <br /> Fee Amount: Amount Paid 3,5 W Payment Date tZ. Z t <br /> Payment Type Invoice# Check# Z I�JIP Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />