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SAN JOA,_tN COUNTY ENVIRONMENTAL HEAL]H DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-A 2 69 <br /> WNMORATO)R2 CK If BILLING ADDRESS <br /> el <br /> FACILITY NAME �J ((��j <br /> SITEADDRESS JI �U'L l y- C, c, FZip <br /> Street Number Direction Street Name cit Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> sret et Number Street Name <br /> STATE zip, c <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# G <br /> -PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> /1� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <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 ENviRONNfENrAL 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 JOAQUrN <br /> COUNTY Or ' ance Codes,Standards,ST and FEDERAL laws. <br /> APP CANT'S SIGNATURE: DATE: <br /> 2 � <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 ENVIRoNNfENTAL 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: �J9G I�pVLS� c� PAYMENT <br /> COMMENTS: RECEIVED <br /> JUN 0 3 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1 L EMPLOYEE#: DATE: 3 I (( <br /> ASSIGNED TO: VAJ !j S C VLt.` EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: J Z <br /> Fee Amount: 27`r Amount Paidz, — Payment Date �y( <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />