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co a C wt <br /> SAN JOAQUIf. JUNTY ENVIRONMENTAL HEALTH t,: PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR L \ <br /> H n C a- 0J C L C- <br /> FACILITY <br /> If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 6 E < —F�Zlp Code <br /> Street Number Direction Street Name Ci <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PJ Street Number Street Name <br /> CITY STATE ZIP <br /> C ad- S <br /> PHONE#1 ExT 7PN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / ERVICE REQUESTOR <br /> REQUESTOR a <br /> C2 ,/-9 CHECK if BILLING ADDRESS <br /> BUSINESS NAME / PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �j, STATE�, zip 1 S <br /> / <br /> CA— <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 1 have prepared this application that t to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and ERAL laws. <br /> PPLICANT'S SI NATURE: DATE: <br /> PROPERTY/BUSINESS OWN'El OPERATO /MANAGE OTHER AUTHORIZED AGENT❑ <br /> NG PART}',proof of authorization to sign is required Time <br /> IfAPPLICANT is <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: , <br /> COMMENTS: RECEIVED <br /> JUN 0 1 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> b <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: <br /> Fee Amount: r� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(134den Rod) <br /> REVISED 11/17/2003 /J// <br />