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SAN JOAQUIOUNTY ENVIRONMENTAL HEAL T EPARTMENT <br /> 1 4 ' If SERVICE REQUEST <br /> Type of Business or Property FACILITY IDA SERVICE REQUEST# <br /> OWNER i OPERATOR 5/ � O <br /> la) Lld C],L CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS v ��+y/,►/ (��] / <br /> Street Direction ` V treat NIme Cr <br /> 21,Ci� <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#T EXT. BOS DISTRICT LO59Ilp ODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �.� IC CHECK if BILLING ADDRES <br /> BUSINESS NAME PHONE I v�O ExT. <br /> HOME Or MAILING ADDRESS <br /> CITY ^ STATE zip �v <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 have prepared this app 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE- DATE: — C� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> I,f'APPLICANT is not the BILLING PARTY,proof'o,�'authorization to sign is reQulr 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: <br /> COMMENTS: <br /> RECEIVED <br /> Nov 0 3 2010 <br /> SA�lCOUN <br /> fiEjALTri DOTMENT <br /> ACC TED BY: EMPLOYEE#: DATE: <br /> ASSIG O: U5 EMPLOYEE#: DATE: 11 2 C) <br /> Date Service Completed (if already Completed): SERVICE CODE: 1 P I E: aJ3�8 <br /> Fee Amount: Amount Paid Payment Date `\ S I 0 <br /> Payment Type Invoice# Check# \ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />