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SAN JOAQU*COUNTY ENVIRONMENTAL HEALT&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR �7 <br /> '� <br /> /l l CHECK if BILLING ADDRESS <br /> FACILITY NAME Z—Tc j (�d a /( ,"✓fin �\ /` U P--I�ZT <br /> SITE ADDRESS J( ffi ? p U s r�!�[� 7 <br /> Direction <br /> Street Number 7 G Street Name U city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S�q Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR l^ ./ CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONUE# 1` ex <br /> HOME or MAILING ADDRESS j�'(�/ 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,Standards, STATE nd,FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: , - (( - / 3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLIcAArT 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. P <br /> TYPE OF SERVICE REQUESTED: RECE <br /> COMMENTS: JAN 0 4 2013 <br /> SAN <br /> HE ENV RQOW CpUNTy <br /> ALTH )EpART/A/_ <br /> ACCEPTED BY: EMPLOYEE#:�� 1 p DATE: I I '7 <br /> ASSIGNED TO: SYS Zt; Q EMPLOYEE#: 0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: �� <br /> Fee Amount: U Amount Paid -3-75 Payment Date 1 /L4 1 ' <br /> Payment Type j t� Invoice# Check# VISA-SA- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />