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SAN JOAQUINIOUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Ty a of Business or roperly FACILITY ID# SERVICE REQUEST# <br /> �' 5 L:� t b-y-) 1 2 kkcD �-312C <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Cj'!q'�1�1i7�� C✓' //� (111 <br /> FACILRY NAME /�j // „ L� Orn f- P ✓n <br /> SITE ADP S�5 S I L�tJ S �I,C �L'�i'L,1.. e <br /> �-(� Street NumEer Direction deet Name Ci Zip Code <br /> HOME or MAILING A RESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex.. Ap f1# LAND USE APPLICATION# <br /> I qL, � - 2-H3% <br /> PHONE#2 EXT. BO$DISTRICT LOCATION CODE <br /> ( off) D6 - q "At 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS E] <br /> ,YohN �tLn QU'- <br /> BUSINESS NAMETe Pefirdicuty) PH E# EXT. <br /> HOME or MAILING ADDR S FAX If <br /> CITY , cJ� raxr�e �v STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this appli tion and that the wor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandards, STA' .and FED F At laws. 1 <br /> APPLICANT'S SIGNATURE: ✓`J� DATE: ©�'��I I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> if APPLICANT is not the BILLING PARTY Proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the pr MeNa <br /> ated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmsment <br /> information to the SAN JOAQUIN COUNTY ENV]RONMENTAL HEALTH DEPARTMENT as soon as it is available and a it is <br /> provided to me or my representative. SEP - ] 20111 <br /> -AN JOAOUIN COUNTY <br /> TYPE OF SERVICE REQUESTED: , <br /> COMMENTS: n , NEALTH DEPARflWNT <br /> I�sJ�f I A I1L,,e . R , dVe--7a <br /> 'Y �N ✓'I )Z1 H. S�1ti�2- /� —itIt "t 'z <br /> clerev p-cdLie=f - <br /> ACCEPTED BY: - EMPLOYEE M -C. DATE: y t, <br /> ASSIGNED TO: EMPLOYEE M lJ DATE: l D <br /> Date Service Completed (if alre y completed): SERVICE CODE:[� PIE: Z <br /> Fee Amount: e3 7 5 c Amount Paid Payment Date C( <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />