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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GU -r z t✓ 'dgp-5 n <br /> OWNER f OPERATOR CHEcx If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /tf f/Z �!�/f i� ���� ,K f�Q/+� 9✓�3_�P <br /> Street Number Direction Street Name Ci 2i Cada <br /> HOME or MAILING ADDRESS (lf Different from Site Address) <br /> 17 7 Street Number Street Name <br /> STATE ZIP <br /> CITY G�itlhL`�✓ �A. 9�Z 3 ee <br /> PHONE#1 ExT. LAND USE APPLICATION# <br /> ) APN# <br /> 83'✓f �.79Z3—Z7D-dna D7 d8 <br /> �PHONE#2 BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESso" <br /> AA4,62 <br />" � EzT <br /> BUSINESS NAME PHONE# <br /> 3� <br /> b t e-Lb 1413 <br /> HOME or MAiumG ADDRESS F # <br /> d77-3 <br /> l3 <br /> CIS, STATE ZIP <br /> o� C 6Z4b., <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized. agentof 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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards,STATEd FEDERAL la s- <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ©7uthorizadon <br /> OTHER AUTHORIZER AGENT ,f� <br /> If APPLICANT is not the BILLING PARTY proof of 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 environmentaUsite 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 /> PAYMENT <br /> COMMENTS:r COMMENTS: � �{� ) �n���� RECEIVED <br /> ' JUN 2 i <br /> 2011 <br /> ��rY� • _ SAN JOAQUIN COUNTY - <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN?.- - <br /> I ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: y <br /> EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE. P l E: f <br /> iii Fee Amount: ' Amount Paid Payment Date I . <br /> I Payment Type Invoice# Check Received By: <br /> EI-IO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />( <br />