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SAN JOAQUIN--sOUNTY ENVIRONMENTAL HEALTH DE;-x(RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> LC— CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 7r- C <br /> (- Street Number DClr�ection r� �3t er eTN.me v �'—+ '-p 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# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR , <br /> REQUESTOR ^� 121, <br /> J t�� n / /-{��LQ CHECK If BILLING ADDRESS <br /> BULESS ME t v PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX <br /> CITYfi�� !i In <br /> ' STATE(�Q ZIP 9 C�l <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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, S TE a FEDERAL laws. J <br /> APPLICANT'S SIGNATUR v„ ,��' DATE: <br /> {{ t� <br /> PROPERTY f BUSINESS OWNER❑ OPERATO GER OTH AUTHORIZED AGENT C� CC LC/ � _ <br /> If APPLICANT is not the BILLING PARTY,proof of author ation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provided t0 me or <br /> my representative. r�/ <br /> TYPE OF SERVICE REQUESTED: L1 S l (/ v " PAYMENT <br /> COMMENTS: p Er oV <br /> f <br /> FEB132014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMF-NTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ^n n I EMPLOYEE#: W U DATE: 2_113 f <br /> ASSIGNED TO: /�✓I / (), ? EMPLOYEE#: 1((- 2—(- DATE: I <br /> Date Service Completed lif already cco'm�pleted): SERVICE CODE: C73q PIE: �3o 4, <br /> Fee Amount: If-7 9(D Amount Paid Payment Date / <br /> Payment Type Invoice# Check#klgW Re eived By:. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />