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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME r —Cu ,� n , C fiU rr,ole �{r�- <br /> l_111D <br /> SITE ADDRESS 2G(DU C— <br /> SLL D V V 1Gw•City(L rR, 9Zin2 <br /> 91 Direction 5treetNametreet Number <br /> Code <br /> HOME Or l) LI ADDRESS (If Differe from Site Address) <br /> I 1 S ' h� <br /> � l.. ,Nu r (A.',r <br /> Street Name <br /> CIN STATE ^ ZIP <br /> PHONE#1 Y l ExT• APN r". rLANSE APPPPLLIICATIONPHONE#2 Exr. STRICT LOCATI N CODE <br /> ( ) <br /> 00 -2- <br /> CONTRACTOR <br /> CONTRACTOR/ SERVICE REQUEST®R <br /> REQUESTOR n <br /> C �.1 CHECK If BILLING ADDRESS Lid <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 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, STATE and FEDERAL laws. yy <br /> APPLICANT'S SIGNATURE: DATE: t <br /> PROPERTY/BUSINESS OwNEi iRATOR/MAN ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPLICANT Is not the BILLING PARTY roof 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same Ql� It is provided to me or <br /> my representative. awl <br /> r Y <br /> TYPE OF SERVICE REQUESTED: ^ cEl <br /> ft <br /> COMMENTS: JAN 0 9 2015 <br /> MA ENV ROP4 CpuN <br /> EAITI-r pE gETENT}' <br /> ACCEPTED BY: 1/1 - n l/� EMPLOYEE#: DATE: P / <br /> ASSIGNED TO: EMPLOYEE#: DATE: I <br /> Date Service Completed (if alreaclompleted).' SERVICE CODE: O I PIE: <br /> Fee Amount: '?)D r---- Amount Paid ¢r3o Payment Date I q/1 5 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-02.5 <br /> SR FORf•.S(Golden Rod) <br /> 07/17/0° <br />