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SAN JOAQU_ COUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or P77a <br /> �- FACILITY ID# SERVICE REQUEST# <br /> 19.� �6" 00 2-1 ;;7�, <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �C�1d//�C Q ( J (�_ 1V <br /> SITE ADDRESS <br /> Street Number Direction & Street Name Cf Zip 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> c'otorv� y CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# C—?& 6 <br /> i 1 q ' <br /> HOME or MAILING ADDRESS FAX# e 4 <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.and FEDERAL laws. > a <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not theBILLINGPARTY,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 ST- l v <br /> COMMENTS: JAN <br /> 4 2013 <br /> �F E"o®1W" ®UN <br /> �LTN®EpA� ��� <br /> ACCEPTED BY: EMPLOYEE M/�n r ®� DATE: p <br /> ASSIGNED TO: ( 2� (� EMPLOYEE M �} DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I b P1 E: <br /> Fee Amount: .� Amount Paid -7 Payment Date E / 1 <br /> s <br /> Payment Type o Invoice# Check# �k Received By: , <br /> - 0 6 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />