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SAN JOAQ. rN COUNTY ENVIRONMENTAL HEALT...JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 14 ie\'�Q , SvJ� H�"000 -516O'0&9&42- <br /> OWNER <br /> 52O'0&9 42- <br /> OWNERIOPE T R <br /> tI /' ' i CHE BILLING ADDRESS <br /> FACaRY NAME AV w—uw 1A U <br /> {'V <br /> SITE ADDRESS �� S L�Y�-Wu�� ��A�( � LGA ( � <br /> Stroet Number Irectl S me Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) T <br /> / Street Number / beet Name <br /> — <br /> CITY STATE ZIP <br /> PHONE#1 ExT. ALAND <br /> PN# USE APPLICATION# <br /> PHONE#2ExT. BO$DISTRICT u� LOCATION CODE <br /> ( �LTfI• `D G L1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS[:] <br /> BUSINESS NAME PHONE# Ez1' <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,SXAT50-n-&TFDPLAL laws. t o� <br /> APPLICA SIGNATURE: DAT' /o��[/ 3 <br /> PROPERTY/BUSINEss OWNER OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTP proof of authorization to sign is required Tate <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: W 5"t�AA-T oi-L RF T <br /> COMMENTS: /_�uk Ow ,vCDEC 0 2 2013 <br /> SAIV V 1 1V gQWN <br /> HEgLTH RDOqE T AIL <br /> ACCEPTED BY: . ^V-G-'e C EMPLOYEE#: DATE• 1.2 Iv I--T> <br /> ASSIGNED TO: �t, L L V,1A A,.C�(_ S EMPLOYEE#: DATE: �r <br /> Date Service Completed (if already completed): SERVICE CODE: ��j PIE: <br /> Fee Amount: Z 7 Amount Paid /a Payment Date <br /> Payment Type - Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />