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SAN JOAQUI0OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 645 TfA r�fo 3� 6l�(31P <br /> OWNER i OP RATOR <br /> CHECK If BILLING ADDRESS Kr <br /> S <br /> FACILITY NAME doe <br /> 7,6 <br /> SITE ADDRESS /J�,,,_�A� <br /> 57 Street Number Direction ` �// Street Name Zi 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 /> ( ) �3;t - 136'7 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P NE# ExT. <br /> �Gr i <br /> HOME orILING 4kDRESS FAX# <br /> I 1 -1117 <br /> CITY STATE elf ZIP 05-7/ <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: AJ1, DATE: 1113140 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ir <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: U v" <br /> COMMENTS: X 1 <br /> 9/ fj'GL I�� gpip RECEIVED <br /> Y NOV 0 3 2010 <br /> 7Y <br /> ACCEPTED BY: n EMPLOYEE#: rry D NVIRONMENTAL <br /> V-) I-IWTH DEPARTMENT <br /> ASSIGNED TO: EMPLOYEE#: !�, f DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid '9( 3 G L. 00 Payment Date L[ (3 <br /> Payment Type Invoice# Check# 9 03) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />