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t <br /> SAN JOAQ l OUNTY ENVIRONMENTAL HEAL11. _r;cPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P—0 u L!iz!011-41-)- -= <br /> OWNER/OPERikTCR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME k RC O AM PM —✓ I v� <br /> SITE ADDRESS �j O J t SO eJ A Y S7'�C y TC�IJ q,50?O) <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) *15- O C—,�7d <br /> Street Number Street Name <br /> CITYy 1 STATE ZIP <br /> PHONE#1 �/�V�!I('r ry EXT. APN# LAND USE APPLICATION# <br /> ( , <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> L4 Celt Pk �..� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS 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 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 /> APPLICANT'S SIGNATURE: 2I DATE:to <br /> al 2"7 <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ 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: <br /> PAY,• <br /> REC. <br /> ' SEP 2 7 2012 <br /> SAM JOAQUIN COUNTY <br /> ENYWONMINTAL <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D P I E: �J <br /> Fee Amount: Amount Paid l�C� Payment Date !/ <br /> Payment Type Invoice# Check# ` Z Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />