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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> SRoo4o3oSo <br /> Typ@I of Business or Property FACILITY ID# SERVICE REQUEST# <br /> •,J{-b 323Z <br /> OWNER/OPERAT R <br /> ( ,1 � 2 ^ CHECK II BILLING ADDRESS <br /> FACILITY NAME 1�/� ^-� nu �r ` ��1 ' ��c ` , y-g(-v <br /> SITE ADDRESS _21(,� '1 ' :J'f( v1 l.e 4Lf <br /> 0. <br /> Street Number Direction Streal Name C L Code <br /> HOME or M NG ADDRESS �If�Diff/erent frotr(l�SitW dd ess) <br /> 1 / (� S lJ(n�L�(�� Y/ Street Number Street Name <br /> CM I-Lc l� q 537? STATE ZIP <br /> PHONE J),1 EMi• APN# LAND USE APPLICATION# <br /> (VI) �v2T <br /> PHONE#291 ERT, SOS DISTRICT LOCATION CODE <br /> ((� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE and FE HAL I9IZ4�APPLICANT'S SIGNATURE: Gs; DATE: <br /> PROPERTY/BusiNEs5 OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> /f APPLICANT is nor the BILLING PARTY proof of authorization to sign ITS 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: YM ENT <br /> COMMENTS: RECE <br /> �� \\ JUL 2 0 2011 <br /> SAN JOAQUIN <br /> COUNTY <br /> IRONM NTAA <br /> ENV <br /> HEALTH DEPARTMENT <br /> DATE:BEMPLOYEE III: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Service Completed (if already completed): SERVICE CODE; Y/ <br /> 7 <br /> Fee Amount: I Dw Amount Paid L; �; Payment Date <br /> Payment Type Invoice# Check# I t, ]--z Received By: _ <br /> EHD 4"2-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />