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SAN JOAQ—.- i COUNTY ENVIRONMENTAL HEAL. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property =FACILITY ID# SERVICE REQUEST# <br /> �✓�CC 7oi 3 <br /> NER/OPERATOR <br /> CHECK if-ADDRESS BILLING _ <br /> ACIUTY NAME <br /> ail,I <br /> SITEADDRESS <br /> Street Number Direction Str t Name <br /> Cit 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> CITY e <br /> STATE ZIP <br /> PHONE#1 Exr. APN# <br /> ) /� `y�TO LAND USE APPLICATION# <br /> PHONE#2 J j(/ ExT. <br /> BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> l.t. /� s CHECK if BILLING ADDRESS <br /> BUSINESS NAME . PHONE# y EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE � ZIP �� !y <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 ENVIltoNIvfENTAL HEALTH DEPARTivIENT 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 and FEDERAL /J <br /> APPLICANT'S SIGNATURE: DAT <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/N'IANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORINIATION: 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. ii <br /> TYPE OF SERVICE REQUESTED: l`�J a 5 AYMENT <br /> CChVMENTS: � V1E JUL 23 2014 <br /> SAN JOADUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7- z <br /> ASSIGNED TO: EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: > l Z IP <br /> I E: Lt b <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type % Invoice# Check# Received By;, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />