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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ ERATOR <br /> Q , P/J e 117 <br /> CHECK if BILLING ADDRESS <br /> JAI FACILITY NAME % W, <br /> SITE ADDRESS 7 '7 } <br /> Street Number Direction Street Name it / Zi Code <br /> HOME orf/MAILING RES(If Different from Site Address) <br /> dL. Street Number I/ `I Street Name <br /> CITY STATEC�' ZIPg5— Z 7 <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# / l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> _ CONTRACTOR/ SERVICE REQUESTOR <br /> RECQUESTOR j �^�1 l w /t / CHECK if BILLING ADDRESS <br /> BUSINESS NAME S PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, th/de' roperty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specNTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my businesthis form. <br /> I also certify that I have prepared this applicawork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA ws. ) <br /> APPLICANT'S SIGNATURE: DATE: / / ✓1/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGERJR 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, 1,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: PAYMENT <br /> COMMENTS: RECEIVED <br /> DEC 13 2011 <br /> .. v JOAQUIN COUNTY <br /> EN141RONMEMTAL <br /> t::ALTH DEPARTMENT <br /> ACCEPTED BY' (�� DATE: <br /> EMPLOYEE#: / <br /> 1 <br /> ASSIGNED TO: EMPLOYEE#: J 'Z� DATE: <br /> Date Service Completed (if already completed): SERVICE!CODE: D P/E: 6 2— <br /> Fee Amount: Amount Paid 1 Z Payment Date 1� <br /> Payment Type C. Invoice# Check# M6 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />