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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> Type o.Business or Pro pe FACILITY ID# SERVICE REQUEST# <br /> `1&o �-797 6,2 ©c&"43 <br /> OWNER/OPERATOR <br /> /gyp CHECK if BILLING ADDRESS <br /> FACILITY NAME `Ur+ <br /> { I � <br /> SITE ADDRESS <br /> Street Number Direction � od <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 /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR--__ <br /> REQUEST R <br /> o I CHECK if BILLING ADDRESS <br /> BUSINESS NAMEMR/� I/�yPHO EXT. <br /> ) <br /> HOME Or MAILING DRE S F # <br /> CITY r STATE ZIP <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 plic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,STA E and FEDERAL ��AA <br /> APPLICANT'S SIGNATURE: /W t✓ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 'hlhfia <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tr Ti I e <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 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: C,lvT y, �j T PAYMENT <br /> COMMENTS: RECEIVED <br /> MAY 3 1 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: �;. DATE:`!�`�/ <br /> ASSIGNED TO: EMPLOYEE#: ,4 ( <br /> , DATE <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ,230ff <br /> Fee Amount: j� Amount Paid Payment Date 513( l <br /> Payment Type ✓ Invoice# Check# t 5 Received-6y.- _ <br /> EHD 48-02-025 ` SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />