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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r � li oC) 33 <br /> OWNER/OPERATOR JZ1� ,r%ot-A <br /> v �'/ I CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /11J?ll"n A/ �� T" � Q 45:;a�O <br /> Street Number Direction Street Name C i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION A <br /> e, 5 <br /> PHONE#2 Ext. BOS DISTRICT /7 LOCATION ODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / ,�j,����2 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �j�r. Pr# x/ T <br /> En <br /> HOME or MAILING ADDRESS L( FAX# i'7� <br /> (7wj 0'7,73 <br /> CITY GOD/ STATE ZIP gcay, <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,STATE and FED fdAL laws. <br /> APPLICANT'S SIGNATURE: DATE: //Ll /T <br /> PROPERTY/BUSINESS OWNER El OPERATOR/A AGER ❑ 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, 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: <br /> COMMENTS: <br /> klEpccr < NOV 14 2012 <br /> r &05 60-17-c> SAN JOAQUIN COUNTY <br /> / ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> 0 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /lo EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P I E: 3 <br /> Fee Amount: Z,SQ Amount Paid a 5D• Payment Date It 141 1 Z <br /> Payment Type ✓ ' Invoice# Check# 12-1342 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />