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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DL-?ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPER&IPR <br /> S i7 CHECK If BILLING ADDRESS <br /> FACILITY NAME L ' I V �i I 1 (/1 <br /> SITE ADDS q S <br /> )�S( C -j�-�cr��Y►� l�-�.� SSP <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (ifDifferent from Site Address) <br /> S K w ^ 4'L Street Number Street Name <br /> CITYqv - STATE Zip. <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) L_ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ STOR <br /> / ` j�/15 /� CHECK If BILLING ADDRESS <br /> BUSINESS NAMED <br /> � O/�// / l / /� PH 7� EXT. <br /> HOME or MAILING ADDRESS (/`/ FAX# <br /> CITY�� STATE ZIP <br /> BILLING_AC'KNOWLEDGEMENT: I. the undersigned property or business owner, operator nr authorized agent of same, <br /> acknowiedge 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, ST TE a�d�ED^�,ws. <br /> / <br /> APPLICANT'S SIGNATURE: l/ DATE: <br /> PROPERTY/BUSINESS OWNER) OPE ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHO'aZATION TO RELEASE INFORMATION: When applicable, 1, 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: �(,� RECENED <br /> APR 16 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> za <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already c pleted): SERVICE CODE: 2 ? P/E: (� <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 />