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SAN JOAQUPCOUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> \rlrlllStreet Number rection �SLWR Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Differe t from Site ddress) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRA OR/ SER ICE REQUESTOR <br /> REQUESTOR t <br /> ��� �� � � _ � I_ CHECK If BILLING ADDRESS <br /> BU INES bN P*E# c�Q EXT. <br /> 'Uopit or MAILING ADDRESS FAX# <br /> CITY STATE • ZIP 9�s$ <br /> BILLING ACKNOWLEDGEMENT: I, the unde igned proper or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific E VIRONMENTAL H LTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as ' entified on this form. <br /> I also certify that I have prepared this applicati and that the work to be p formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards; TATE nd FE ERAL laws. <br /> APPLICANT'S SIGNATURE- , i'" — DAA&-Z <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR/MANAGER OTHER AUTHO IZED AGENT <br /> Lf APPL/CANT is not the /LUNG PARTY proof of authorization t0 signn •s required Title <br /> AUTHORIZATION TO RELEAS INFORMATION: When applicable, 1, the owlper or operator of the property located at the <br /> above site address, hereby autho <br /> information <br /> the release of any and all results, geotechnical data and/or environmental/site assessment <br /> 1rif01atiOn t0 the SAN JOAQU[N OUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOCI as it is available and at the Same time It is <br /> provided to me or my represent ive. <br /> TYPE OF SERVICE REQUESTED: (, UTRWMENT <br /> COMMENTS: RECEIVED <br /> SEP 13 2010 <br /> SCAQUIN COUNTY <br /> J <br /> JNVIRONMENTAL <br /> H TH DEPARTMENT <br /> ACCEPTED BY: �� 11 EMPLOYEE#: 0? DATE: 3 <br /> ASSIGNED TO' EMPLOYEE#: GLf DATE: CZ <br /> Date Sery a Completed (if already completed): SERVICE CODE: 0`:l P U <br /> Fee Amount: b . L/0 Amount Paid Payment Date `, 3 D <br /> Payment Type Invoice# Check# eived By <br /> EHD 48-02-025 T (LV.-, N �v E r pq--r� SR FORM(Golden Rod) <br /> REVISED 11/17/2003vvv��� <br />