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SAN JOAQUIN "�WNTY ENVIRONMENTAL HEALTF' `NEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U5:1LGZ4 �7-P�- 7 q _� <br /> OWNER/OPERATORr <br /> /—IAIZ�& �� /// CHECK It BILLING ADDRESS❑ <br /> FACILITY NAME /� ) 7 <br /> SITE ADDRESS � i"j� Gi� 0 5 T S�L'CKTI:�/ �S�p <br /> Street Number D/?/ Y Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> J Stre%t Number Street Name r! <br /> CITY —12 C�fi_ /O STATE CA ZIP n � <br /> /'/.� t/ <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( � I <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / � �j /� CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME CJr- ExT. <br /> HOME Or MAILING ADDRESS35- /, C ,ASG w -57— FAX# <br /> CITY /� ( /V G STATE C ZIP <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 /> 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 ws <br /> APPLICANT'S SIGNATURE: DATE: �v <br /> PROPERTY/BUSINESS OwNEVIR_ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: i PAYM <br /> COMMENTS: EIVED <br /> c�-L� NOV 19' 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRNMENT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: , DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com eted (i beady completed): SERVICE CODE: P/E: <br /> Fee Amount: (fib Amount Paid -!5? I"7--�, c) c::) Payment Date � <br /> Payment Type l Invoice# Check# C 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />