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SAN JOAQU :OUNTY ENVIRONMENTAL HEALTE _PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r 0 0 6 q J7P/-- <br /> OWNER/OPERATOR <br /> _ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 1"Z LT,4,C <br /> SITE ADDRESyS;7� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t Street Number L� Street Name <br /> CITY STATE ZIP <br /> 61 - _`7,40 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (210 ) 33%. - -72- % 8 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR y <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �--- <br /> PHONE# EXT. <br /> CA-ECT <br /> c_ JZ—� 6 L N t=r=te 2c ev �P/ L C- 7Svcs <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY Gtr /' STATECA_ ZIP 1? <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that I have prepared this app licatio and that the Wo be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards-, STA nd FEDERAL S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPER'rY/BUSINESS OWNER❑ OPERATOR/K ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING 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 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: <br /> COMMENTS: 4 w( giow <br /> MAY 16 2012 <br /> SAN JOAQUIN COUNTY <br /> EWRONMENTAL <br /> HEALTH DEPARTAEST <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: ' + EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:lhol <br /> Fee Amount: I Amount Paid "�'-1 �i Payment Date <br /> Payment Type r Invoice# Check# Z > �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />