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SAN JOAQL�COUNTY ENVIRONMENTAL HEALTA-bEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RL�,li� 10411-td- fi oa U a20 is � <br /> OWNER 10 ER TOI2 CHECK If BILLING ADDRESS 13 <br /> Sc^t. RO'+J PLA 7- <br /> FACILITY <br /> FACILITY NAME %C-. 10/WT n <br /> SITE ADDRESS 101 /A) I f"/'�I`N S / ,R1,96 N 536 <br /> Street Number I Direction Street Name Citx Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) X- <br /> 21 I j F C— l 6) ( a'treel Number ree Na <br /> CITY C�C�S STATE.'^ ZIP -3a ---;L <br /> PHONE#1 EXr• APN# LAND USE APPLICATION# <br /> ( W) G7-7 - (G6 l 2�1- 6 60 - 7 4 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> 1 1 <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 an DERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: <br /> Q J4 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[I <br /> IJAPPLICANT 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 environlnental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and.ij V;T same time it is <br /> provided to me or my representative. yknI <br /> TYPE OF SERVICE REQUESTED: ( ai/1 IVF <br /> COMMENTS: 4 2014 <br /> SAN iVAQUt <br /> Hfry <br /> gLTN RD.AE TM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: / N. �Lj <br /> ASSIGNED TO: L EMPLOYEE#: DATE: T <br /> Date Service Completed (if already completed): SERVICE CODE: SZ3 PIE: <br /> Fee Amount:42 G O Amount Pal&/-,, .im Payment Date <br /> Payment Type Invoice# Obeck# Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />