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SAN JOAQUIN 17OUNTY ENVIRONMENTAL HEALTFT DEPARTMENT <br /> SER'V'ICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1�G5 Si� �5 Slr�o t� t (g <br /> OWNER/OPERATOR �\ <br /> \ l <br /> (\) CHECK If BILLING ADDRESS <br /> FACILITY NAME )o'��l � <br /> SITE ADDRESS (-21 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> NA Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -- - -- - — . <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ( 7 T U PHONE <br /> HOME or MAILING ADDRESS FAX# <br /> ( �) -- 6 <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 or <br /> 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 /> k <br /> APPLICANT'S SIGNATURE: *--on VJLI��C, DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 /> �/ <br /> TYPE OF SERVICE REQUESTED: u�jT 720 f%1 I AYMENT <br /> COMMENTS: R <br /> Eut <br /> AUG ^ 3 2011 <br /> SAN NIMENTAL� <br /> H�TH DEPARTMENT <br /> ACCEPTED BY: / ow EMPLOYEE#: (f a�'g DATE: 3 1 <br /> ASSIGNED TO: (!ACA t r EMPLOYEE#: t (Cf2-Z DATE: '4 3 f <br /> Date Service Completed (if already completed): SERVICE CODE: -I Y P i E: <br /> Fee Amount: Amount Paid 53-7S-. (:)0 Payment Dcate 3 <br /> Payment Type Invoice# Check# b� s Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />