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SAN JOAQI, COUNTY ENVIRONMENTAL HEALIOEPARTM.ENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (7- 1) t <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRE <br /> FACILITY NAME N-b-Z <br /> % �c <br /> SITE ADDRESS j { N`- � f 1t �� . / `�P(�- T6i�cit�4V <br /> S1tr_elet Nuon `J ` ,Vme Zi Code <br /> HOME or MAILING ADDRESS (If Differ nt fro Site Address) 1-71 3 `'-z5-'1'�0 Ve <br /> J '1� Street Number Street Name <br /> CITY O STATE ZIP S 12. <br /> PHONE#1 _ EXT. APN# 3 !n LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICTCATION CODE <br /> CCS m(Zig V a I F <br /> G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS E] <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,STATFADsLEYDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: k I—, 6 b (T <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 0 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: I`�'h e-:1- C(/1/1 C-A c' L PAYMENT <br /> COMMENTS: R <br /> JAN - 6 2014 <br /> SAS COUNTY <br /> SR HMENTAI. <br /> HFJgLTM DEPARTMENT <br /> ACCEPTED BY: y� / EMPLOYEE#: C�, '�'L; DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: �J <br /> Date Service Complet (if already c mpleted): SERVICE CODE: Z PIE: <br /> Fee Amount: 2>"l S Amount Paid Payment Date l <br /> Payment Type Invoice# Check#J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />