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SAN JOAQU*OUNTY ENwRoNMENTAL REALTAOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prope FACILITY ID# rSERVICE REQUEST# <br /> OWNER/OPERATOR � , , <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 3a E:I <br /> Street Number Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street N r Street Name <br /> CITY �_._._ STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ry; , ,�.�-� P <br /> (0 Exit— <br /> HOME or MAILING ADDRESS <br /> LA <br /> CITY il�) T STATE zIP � <br /> r <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,Sta rds,STATE and FEDERAL la I ' ,r <br /> APPLICANT'S SIGNATURE: � W I f TUU � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q`11 <br /> If APPLICANT is not the BILLING PARTYY,proof of authorization to sign is require 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 D ARTNfENT as sQQn as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMEMS: <br /> PAYMENT <br /> RECEIVED <br /> NOV 0 9 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCE D By, EMPLOYEE#: H <br /> ASSIGNED TO: EMPLOYEE#: �6 DATE: <br /> Date Service Completed (if alrea .completed): SERVICE CODE: / P i E: '7��� <br /> Fee Amount: O� Amount Paid 3(o , (7 O Payment Date `L /GY� <br /> Payment Type Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />