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SAN JOAQUINL"OUNTY ENVIRONMENTAL HEALTH MI�ARTMENT <br /> SERVICE REQUEST <br /> T,y�of Business or Propeft q FACILITY ID# SERVICE REQUEST# <br /> LbLs ko�+oJ C&�Lct�" `�' 0o Q I S o (7S ' <br /> 4 OWNER/OPERATOR r/� A�j <br /> ` S c-_v, I/- CHECK If <br /> BILUNG <br /> FAcum NAMbA- <br /> t 11 <br /> SnE ADDRESS <br /> V StrodN.lm &S ..nn c ,' 1' [J Crc <br /> HOF AAAI ADDR (If Differe from Site Address) <br /> -T�. Svset Number t <br /> CITYTE <br /> �4 <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> 1 ) <br /> PIXN E#2 En. BOS DISTRICT LOCATION CODE <br /> l 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BIWNG ADDRESS <br /> BUSWEss NAME PHONE# E", <br /> HOMFfr Mm%NO ADDRE (AX# 1 <br /> rU ( QQ <br /> CITY STATE MP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 apps' ion and that the wor '11 be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar A and FEDERAL '\ <br /> APPLICANT'S SIGNAT ` '� V LcS� �-•Lj� <br /> PROPERTY/BUSINESS OWNEgh' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILL/NG PARTY proof of authorization to sign is required Es 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 environmen�'�p]/ ssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at ffi e it is <br /> provided to me or my representative. M� <br /> TYPE OF SERVICE REQUESTED: OCT 2 5 2012 <br /> COIaEMS: tfwu2,o�� Q. tlb 06 QGVL ae. Co S <br /> v7— L � <br /> C'1 �p�at.� !e FIs=/� attQ Note o��zu � e r �icsffrr �7 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Data Service Completed (N already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: , Amount Paid —tj Li.) Paym nt Date C) ( z— <br /> Payment Type ` Invoice# Cfreck# �O R gy <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />