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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Wt-�NER I OPERATOR <br /> V a F'o ., 6.\� :1 CHECK If BILLING ADDRESS <br /> AGILITY NAME <br /> SITE ADDRESS <br /> Street Number I Olrection Street Name ciw Zip Code <br /> /HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 1 Street Name <br /> -CITY I_ GI . STATE (A <br /> zip <br /> CrJ ✓G � <br /> HONE#t E7-714# LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( D �I rl <br /> CONTRACTOR / SERVICE REQUESTOR 1 <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> 0 • t d I 1-�c Lo'� 3 3• -C S <br /> How orMAIUN; ADDRESS FA%# <br /> 22-7 n 01 -.d e.� (Zc3c <br /> C;ITYAcM ' STATE !�,A 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 an EDE laws. <br /> ,Pi�LICANT'S SIGNATU <br /> PROPERTY/BUSINESS OWNERO TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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. I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> JUL 0 5 2013 <br /> 14 y ✓ SANENVAROMEN IAL <br /> HEALTH DEPARTMLNT <br /> ACCEPTED BY: LL EMPLOYEE <br /> ASSIGNED TO: 1. � S EMPLOYEE#: rajt'o OLc/oS DATE: 9 ( I 3 <br /> Date Service Completed (If already completed): :: <br /> ompleted): SERVICE CODE: ��S PIE: 1 l,p� <br /> ' <br /> Fee Amount: � L 7 � A7S <br /> �o2 <br /> mount Paid �,• Payment Date /3 <br /> Payment Type ✓ Invoice# Check# J0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />