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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP BATOR <br /> /\,t CHECK If BILLING ADDRESS <br /> FACILITY NAME Ij( 1�t(_�yS�J <br /> SITEDRESS] C \f,� *J" e' (^n1\�c C Al F�5331 <br /> / Street Number Direction 1YU1 Street Name Cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �(( Jyl�1-�-�� <br /> Street Number - ' Street Nam, <br /> CITY -i;Scare 7rPPHONE#1r IX 1 1C LAND USE APPLICATION <br /> (i !off � F'Ir' <br /> — <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADDRESS I 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 ENvTRONMENTAL 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 an; - AL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2-1 -13 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN'�'.LS�J J <br /> a <br /> IfAPPLTCANT is not the BILLITvG PARTY,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 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 HEALTH DEPARTn4EM'as soon as it is available and at the same it is <br /> provided to me or my representative. f"q/�y c <br /> TYPE OF SERVICE REQUESTED: _ lxt�,+ V`ti� <br /> y �O <br /> COMMENTS: ` <br /> X44' s NO 06 Z <br /> A/V 419 <br /> '4ENVI gQUl/V C <br /> Z/-/FpgRN�NTY <br /> FNT <br /> ACCEPTED BY: f L EMPLOYEE M DATE: ,> <br /> ASSIGNED TO: � �l(, EMPLOYEE M DATE:' --1 071 <br /> Date Service Completed (If already ompleted): SERVICE CODE: L P 1 E: O�� <br /> Fee Amount: (4 L �— Amount Pai /S 2 oz) Payment Date <br /> Payment Type Invoice# Check#Xg L�L Receiv d By: <br /> EHD 48-02-025 �a r/� G,C SR FORM(Golden Rod) <br /> REVISED II/17/2003 1-77•0-' ZZ <br /> .^ T <br />