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SAN JOAQUIN COUNTI' I';NVIRONNII?NTAL H1 ALTH DEPARTNILNT <br /> SERVICE REQUEST <br /> Type of Business or Property n, FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> t7 I <br /> FACILITY NAME <br /> SITE ADDRESS 'VJ icd� l" -T �'AL�� O <br /> ON 5` Street Number DirectiontrCName Gil Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site <br /> y�Address) <br /> 7 7r 1'v f�/I d ' C � W Street Number Street Name <br /> CITYSTATE zip <br /> -f�,� C 5 S1-53 <br /> C. �C3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> v�, ? �42x;,35 <br /> PHONE#2 EXT. 80S DISTRICT LOCATION CODE <br /> Lt <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOII'LLDGENIENT: 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,STATE and FEDERAL laws. <br /> � n <br /> APPLICANT'S SIGNATURE: t �, �, �f DATE: 3/j <br /> Zy I Z— <br /> PROPERTI /BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE,INFORNIATION: 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 JOAQUfN 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: 7vC>D Co/J�t�_C� 7 ,c`� RECEIVED <br /> COMMENTS: n <br /> C4MAR Z 8 2012 <br /> SAN JOAQU N COUNTY <br /> EWI RO N N E WTAL <br /> HFALTH DEPARTMENT <br /> ACCEPTED BY: cjaC,jj,jv EMPLOYEE#: C/�jl DATE: !� <br /> ASSIGNED TO: /� ?��iZ Tyi/1 EMPLOYEE#: t C�Z DATE: 312 -1 <br /> Date Service Completed (if already completed): SERVICE CODE: f P 1 E: (P 2-- <br /> Fee <br /> Fee Amount: f Amount Paid Payment Date <br /> Payment Type ` Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> SR FORM( <br /> REVISED 11/17/2003 Golden Rod) <br />