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SAN JOAQUha COUNTY ENVIRONMENTAL HEALTh.oEPARTMENT <br /> SERVICE REQUEST <br /> ---TType of Business or Property FACI77] SERVICE REQUEST# <br /> eOO �F q <br /> OWNER/OPERATORpp CHECK If BILLING ADDRESS <br /> l <br /> FACILITY NAME G S <br /> SRE ADDRESS Gl 53 <br /> �Streel Nom be, D coon I reef ame Cit 2i C <br /> HOME orMAILINGDDRESS (If Different from Site Address) <br /> 0 00 Street Number Street Name <br /> CITY STATE ZIP <br /> C <br /> PHONE#I ExT' APN# LAND USE APPLICATION# <br /> (�� ) (gra-6oz- <br /> PHONER En BOS DISTRICT LOCATION CODE <br /> kA I 3S- D'7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FA%# <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE FERE Ll vs. <br /> APPLICANT'S SIGNATURE: <br /> DATE: ���✓.�I a <br /> PROPERTY/BUHINESS OWNERG OPERATOR/MANA ER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAPPLLCANT is not the BLLLLNG PARTP 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 a dress, 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: ECEIVE�1 <br /> COMMENTS: MAY <br /> 2 5 2012 <br /> SAN JOAQUIN COUNTY <br /> VWRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L��— szi4j <br /> DATE:ASSIGNEDTO' DATE:Date Service C mp a ed (If already completed): PTE:Fee Amount: r _ Amount Paid t Date �4 5Payment Type Invoice# ChReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />