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SAN JOAQ. , COUNTY ENVIRONMENTAL HEAL' APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s�oG,7 9-7 C? . <br /> OWNER/OPERATOR r <br /> CHECK if BILLING ADDRESS <br /> l <br /> FACILITY NAME )cA GO <br /> SITE ADDRESS nq- o SCJ �,10EJl/( <br /> Street Number Direction tr t Name I ck kc i e <br /> HOMEor <br /> MAILING ADDRESS (If Different fr Site Address) <br /> �C_ CSI✓ Street Number Street Name <br /> CITYC � � STATE ZIP <br /> 1 (�i <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standard TATE and FEDERAL laws. Q 6/ <br /> APPLICANT'S SIGNATURE: aq U 6 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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: (,L,c: c-L y� <br /> COMMENTS: <br /> SEP 06 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIFIOMIENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: A-� _ ��7�/� EMPLOYEE#: Z.G 7 U DATE: �1 / <br /> ASSIGNED TO: V) An) ��d P EMPLOYEE#: /: 2/I DATE: <br /> Date Service Completed (if already completed . SERVICE CODE: (�,/ PIE: ��G J?� <br /> Fee Amount: Z 5 mount Paid / -2_. °`� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />