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SAN JOAQL'tw,,.�COUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#� <br /> Ot t S4- �;tt ?313 S <br /> WN I OPERATOR r CHECK If BILLING ADDRES� / <br /> ma.w� Q� t <br /> FACILITY �` Iv� 34 - <br /> SITE ADDRESS Sp tt J L <br /> Street Name Cit Zi Code <br /> Street Number Direction / so <br /> HOME or MAILING ADDRESS If Different from Site Address) l� <br /> Street Number S reet Name <br /> 'CITY -Zip <br /> Ems• APN# 11hN6 USE APPLICATION# <br /> ( 3 ao I <br /> PHONE#2 EX1. BOS DISTRICT t_oCAT13 <br /> CODE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> I 1 <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 I4EALTH 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 and FEDERAL laws. <br /> APPL,ICANT'S SIGNATFAAf : _�����/L'Can2 � DATE: f <br /> 'PROPERTY IBUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT❑ <br /> IfAPPLlcANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IN1F`ORMATION: 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 JOAQUTN COUNTY ENVIRONMENTAL IIEALTH 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: 4 p� CUA S G C <br /> COMMENTS: v�L� �,� RECEIVED <br /> 2014 <br /> SAN N�pQUIN H9MENTAI-NTY <br /> ACCEPTED BY: tr �� EMPLOYEE#: E: I l S r <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alleady completed): SERVICE CODE: P 1 E: L b 6 <br /> Fee Amount: It v�D Amount Paid `a Payment Date <br /> Payment Type ,/ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />