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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE-QUEST# <br /> Z d <br /> OWNER/OPERATOR 4joq J �� <br /> LFX CHECK if BILLING ADDRESS all <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number direction /Street Name �ff Cit Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) aO. pD� /J Zi <br /> �j /� fj Street Number r IQ Street Name r <br /> CITY wdala a ela,44- STATE �n zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# !a <br /> 47-4--40 <br /> PHONE#Z Ext. BOS DISTRICT LOCATION DE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> f��V►Ijr +I'/ /V� r�' CHECK If BILLING ADDRESS❑ <br /> BUSINESS 1VAIVIE �I) /*Al 4 �� w�� � � I� EXT. [w <br /> HOME Or MAILING ADDRESS w' ��� ���O FAX# .•7 <br /> (AV 33y-47RS <br /> CITY 2W1 <br /> 1 STATE eA ZIP 4?5ZJ1/ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, rn <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 /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL S. <br /> APPLICANT'S SIGNATURE: DATE: 7 �� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGW ❑ OTHER AUTHORIZED AGENT LI <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> �E pG2T�t � RECEIVED <br /> JUL 13 2011 <br /> -SAN JOAAUIN COUNTY <br /> ENVIRONMENTAL <br /> h'Af MENT r f <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: _O EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S' Pi E: <br /> Fee Amount: 2 f t I Amount Paid �' Payment Date r3 20( <br /> Payment Type G� Invoice# Check# Received By: // <br /> EHD 48-02-025 SR FORM(Gulden Rod) <br /> REVISED 11/17/2003 <br />