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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LL�rqi'I F � X2;00 7�s/y <br /> OWNER OPERATOR <br /> Au 4 t G y�c //� J CHECK If BILLING ADDRESS <br /> -rbicCIL�ln NAME/— ' , ` / Ue <br /> SITE ADDRESS <br /> U , , I- � r�c1 c��. 9537 <br /> / Street Number Direction // Street Name t Cit Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY- / STATE L,I ZIP <br /> Ll <br /> PHONE#1 L ExT• APN# LAND USE APPLICATION# <br /> /) 3 233- 36S - I (,, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 cos T <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 'h'" � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> If �35- 3L-/ <br /> HOME Or MAILINGDR�ES,S FAX# _ <br /> 3 ll� ) <br /> CITY�r CI C.C , STATE ZIP 153 ) / <br /> BILLING AC OWLEDGEMENT: 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 a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 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 INFORNIATION: 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. s <br /> TYPE OF SERVICE REQUESTED: 4x/^ 61114 .. <br /> COMMENTS: I-AlYMENT <br /> RECEIVED <br /> SEP 1 1 2014 <br /> SAN ,IOACIUIN COUNTY <br /> ENVIRO MENTAL <br /> ACCEPTED BY: A�jAQt� EMPLOYEE#: ATE:Ll 19 A H+MIENT <br /> � ;1 ;(i <br /> ASSIGNED TO: M - ,�"„ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 P i E: /go/ <br /> Fee Amount: it3G1 Amount Paid Payment Date C1 l".( <br /> Payment Type cf Invoice# Check# :)-9 Is S_ Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />