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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5� 6g � � a <br /> / OWN R/ PERI+TOR� CHECK If BILLING ADDRESSP <br /> I <br /> FACILITY NAME � <br /> SITE ADDRESS ,11➢�3 '•, 0-V'Nt� �V� L l`U.�,..Q,✓� � � Z <br /> Street Number Direction Stra¢t Na me---- City Zip Code <br /> HOME Or IdAILING ADDRESS (if <br /> DDRESS (if Diffe site AddrgSS) ar St . <br /> \/ Street N mbStreet Name <br /> CITY / /f / !(� / STATE ae ZIP <br /> PHONE#/-`-, En. <br /> APN# LAND USE APPLICATION# <br /> L GA /0 <br /> 6d bs318 t' 12 <br /> PHONE#2 En. BOS DISTRICT � � LOCA'rp CEDE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 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 ENViEONMENTAL 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,Standards,STATE d FEDERAL laws. <br /> APPLICANT'S SI? A&URE:� <br /> CPROPERTY/AUSINESS!/O/OWNL OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> — ' IfAPPLIC': rrs notthe B7LLWGPARTP 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: C &'A u �ff Po (v O V t W CC'bt ut,1'/1 r IL " <br /> COMMENTS: QL RECEIVED <br /> JAN 10 2014 <br /> SANENVICOUNTY <br /> hrr <br /> ACCEPTED BY: .1 CL L EMPLOYEE#: ATE: - 7/-17,104)ASSIGNED TO: t.a : t �� EMPLOYEE#: DATE:Date Service Completed (if already completed): SERVICE CODE: C) (, P <br /> Fee Amount: Z S Amount Pald l Payment Date / / /o //`7"/1 <br /> Payment Type Invoice# Check# / Recelved y: 'L(! <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />