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SAN JOAQUIN COUNTY ENVI RONNTENT AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR CHECK if BILLING ADDRESS■ ■ <br /> FACILITY NAME <br /> SITE ADDRESS 6yS� y Wi/,e„/E-P .a! <br /> Street Numher Direction Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY F�11-411H1-7)/V STATE zip <br /> PRONE#'I EXT, APN# LAND USE APPLICATION# `7 <br /> A09) 1/7�j- S37.3 DaS- //o-dy, 0 9 -- //- <br /> PHONE#2 EXT. I30S DISTRICTLDCATIDN CORE <br /> ( ) <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REQUESTOR / - f� ,/ICHECK if BILLING ADDRESS <br /> 4 //�✓ f�9 ICJ ` <br /> BUSINESS NAME PHONE,# ExT'/Ofi/ -r�G1�f � D7) �3 � /3? <br /> HOME or MAILING ADDRESS saO v / +Q FAx# <br /> CITY J�fl� STATE /4 zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific ENV[RONNtrNTAL 1IFALTI-i DEPARTNIFNl hourly charges associated with this project or <br /> activity will be billed to ine or my business as identified on this form. <br /> I.also certify that I have prepared this application and t.114 the work to be performed will be doge in accordance with all SAN JC)AQUFN <br /> COUNTY Ordinance Codes, Standards, ST,eTt=. and FI=iJt: 1_laws. <br /> APPLICANT'S SIGNATURE: DA1'E�:/ <br /> PRCIPF.RTY/Bi l.st;.'F,Sti ONVtiER❑ OPERATOR I t NACFR ❑ OTHER AuTHomzrD AGENT <br /> ff:IPPLAANTis nor die BILLING P:tR7T,proof of authorization to si,n 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 ancUor environmental/site assessment <br /> information to the SAN JOAQlj[N COUNTY" ENVIRONMENTAL HEALTH OFPARTNIT:,N'i as soon as it is available and at the sante tune it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: <br /> r> <br /> COMMENTS: ,<_ r - r I ._ <br /> V41 <br /> t' ��, ..� u-; Cnt,►� , SEP 0 7 2011 <br /> ACCEPTED BY: EMPLOYEE#: 73 DATE: <br /> ASSIGNED TO: r EMPLOYEE#: ! DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P!E: � <br /> Fee Amount: �. ° Amount Paid r Payment Date 6? r <br /> 1 Received B <br /> Payment Type '" ?' - Invoice# Check# ! y: <br /> EHD 4$-02-025 Cr" { " SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />