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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O 2- <br /> OWNER <br /> OWNER t OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS a3 "� S �j��F�f �Q/� gS3 lv6 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name 1 <br /> CITY STATE c::� ZIP <br /> I <br /> PHONE I Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( it <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REG!UE STOR <br /> 40 <br /> Inv yep yey CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME ) /7//I� ✓`��`,�/�•�I - (W7 Z3-e EXT. <br /> HOME Or MAILING ADDRESS L/ �n �/OYx �! O F� <br /> -[/ ( W 370� <br /> GlTY �d/ STATE �� ZIP l <br /> BILLING ACKNONVLEIIGEMENT: 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 or <br /> 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 /> I <br /> COUNTY Ordinance Codes,Standards, STATE an4 FEDEJ4 laws. <br /> APPLICANT'S SIGNATURE: DATE a9 <br /> PROPERTY/Bt)SINF,SS OWNER❑ OPERATOR/ AGER © OTHER AUTHORIZED AGF.NTMt— 5� � <br /> If APPLIC INT is not the BILLING P Y,proof of authorization to sign i5 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 ENVIRONMFNTAL 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: <br /> PAYMENT <br /> RECEIVED <br /> t 1 � „�`. JUN 2 9 2011 <br /> SAN JOAQUIN COUNTY <br /> V4R0NMFNTAL <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE:HEALTH EPA •J s,!/ <br /> 7 r. !/" <br /> ASSIGNED TO: EMPLOYEE M D DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /, PIE: 6a <br /> EeAunt: f— Amount Paid Payment Date ��Type Invoice# Check# 4-1 D- Received By: <br /> l <br /> EHD 48-02-025 SR FORM(Gdlden Rod) <br /> REVISED 11/17/2003 11 <br />