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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTISEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST# <br />A <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME CD u 10 C ltIb '76/ <br />ACCEPTED BY: <br />SITE ADDRESS <br />I <br />? 1 <br />G C. <br />z <br />ASSIGNED TO: <br />�xLuL,l li <br />EMPLOYEE #: <br />Street Numbe <br />Direction <br />Street Name <br />City_Zi <br />Cotle <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Payment Date <br />Payment Type <br />Invoice # <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />12 3�Zel-Z- <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />jj <br />CONTRACTOR / SERVICE REQUESTOR <br />TOR, �/ <br />�-f-/l leen Ile /I S ka- <br />BUSINESS NAME 0 i <br />/ , -ra/ 11--, t O ka�`� <br />HOME Or MAILING DDRESS g - <br />0 2 'l a Ik? / IL !q rT <br />CHECK if <br />PHNE <br />FAX # <br />&Z�S—) 1142-4-3SZ <br />CITYpled (� 4 ,,v STATE 0,4ZIP g t�C�� <br />EXT. <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE:j'�yQ�-�(/ DATE. <br />PROPERTY / BUSINESS OWNER ❑ 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 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 time It IS provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: c�i Cc <br />COMMENTS: <br />RECEIVED <br />JAN $ 2 2014 <br />SAN JOAQUIN COUNTY <br />ENVIAOMETAL <br />HEALTH AENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 1 <br />? 1 <br />G C. <br />z <br />ASSIGNED TO: <br />�xLuL,l li <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: i 1 <br />PIE: l_ 3` 9 <br />Fee Amount: <br />^� <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # — o� <br />eceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />