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SAN JOAQUII 4 *:OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11L 7D ,- - <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ;V\ \\Ck(- � <br /> SITE ADDRESS f o 2C t F �.� �N �SZ�Gj <br /> v TV �l <br /> Street Number Direction treet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �� 1 <br /> Street Number t Street Name <br /> CITY S kC�l/► C'/1 TE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# v <br /> cb <br /> PHONE#2 ExT• BOS DISTRICT11 LOCATION CODE <br /> �%) 2 r �J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 ` cam. �C� <br /> � CD <br /> �� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEi \ � �I _.� �� PHONE# / G/t_(GI Exr. <br /> �j O <br /> HOME or MAILING ADDRESS It FAX# <br /> CITY STATE ZIP <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 /> 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 TE and F ERAL laws. //q /� <br /> APPLICANT'S SIGNATURE:�_ DATE: /V//" 03 / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ V W✓lx <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: )(e, rr.JPAYMENT <br /> COMMENTS: J RECEIVED <br /> 6-- OCT-2 S 2014 <br /> SAN JOAQUIN COUN <br /> TY <br /> ENVIROMENTAL <br /> EALTH DEPARTMEN <br /> ACCEPTED BY: �V`�f 4 EMPLOYEE#: DATE: �p 2 <br /> ASSIGNED TO: GJ t,� S� C� EMPLOYEE#: DATE: /dS <br /> Date Service Completed (if already completed): SERVICE CODE: 061 P I E: d <br /> Fee Amount: (-,too. Amount Paid � �� � Payment Date �p Zgl I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />