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SAN JOAQ*ouNTY ENVIRONMENTAL HEALT ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#5 SERVICE REQUEST,#j <br /> OWNER/OPERATOR <br /> �1 A,T� 1 , CHECK If BILLING ADDRESS <br /> 4:114--1 C <br /> FAciuTy NAME �Q I~ <br /> SITE ADDRESS \r� <br /> -2—" Street Number I Direction Street Name Ci 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 /> ( ► y <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> t-� . � fir-, <br /> BUSINESS NAME PHONE# EXT. <br /> oikLo S6j(2>—logO <br /> HOME or MAILING ADDRESS FAX# <br /> 1k2-(;3 C>ad_A_ Cer��e cz. D��.� (011 LP) 4�b ZS,8 - <br /> CITY �r.6r.c STATE �- ZIP <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 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: �(� Q}Q DATES:: tO <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT W �� <br /> If APPticANT is not the BiLmNG 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: <br /> COMMENTS: <br /> OCT 1 6 2009 <br /> ENVIROWENT HEALTH <br /> ACCEPTE Y: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �! OYEE#: /fj 7� DATE: <br /> Date Service Completed (if already completed): RwcE CODE: / P I E- <br /> Fee Amount: 3V Amount Paid3 S Payment Date p 6 <br /> Payment Type Invoice# Check# $ Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />