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HIEUMV Mu <br /> SAN JOAQ U TY ENVIRONMENTAL HEALTIr <br /> T ANT O 9 ZOQ <br /> SERVICE REQUEST 410A <br /> Type of Businessor Pro FACILITY ID E 1 <br /> 1 11 11 1 <br /> PERMIT/SERVICES I <br /> I ERI OPERATOR <br /> CHECK if BILLICSG ADDRESS <br /> FACIurY PI E <br /> SITE ADDRESS �N r �G7"Zi.Cd. <br /> Street Name <br /> HOME Or MAjuNa ADDRESS (if DuVerent from site Address) <br /> Nunftr <br /> CITY STATE ZIP <br /> PH #7 ExT. APN LAND USE APPUcAnON AI <br /> ( <br /> PHONE ExT• SOS DIS CT LOCATION CODE <br /> CONTRACTORlSERVICE REQUESTOR <br /> EUESTOR CHECK If BILLING ADORES <br /> USINESS NAME PHONE# ExT. <br /> A <br /> HOME orIta DRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNQV6LEDGEMENT: 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 he performed will he done in accordance with all SAN JOAnITIN <br /> COUNTY Ordinance Cortes,Standards,STATE and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATE:�I�C� <br /> PROPERTY/StiSINESS OWNER OPE TOB l MANAGER 13 OTHERAtrMORIZEDAGENT <br /> If APPLICANT is not the BILLING PARTY prot?f of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 CO(,'N'1'Y ENVIRONP. N'I'AL HEAL'I'H DEI'f1R#1E"N'l'aS SOOII aS it i5 available aid at tl w,2.e tti3le it i5 <br /> provided to nye or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED Y: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already co I d): v�E CODE, <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received y: <br /> EFID 48-02-028 See FGRE(Golden Rod) <br /> DEVISED 11/17/2001 <br />