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t � <br /> SAN JOAQU` OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Busin s or Property f FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEC L �� t�J, <br /> 41+ /f Al D 1-11 <br /> SITE ADDRESS �/t�d Cv C,S�' // / <br /> Street Number Direction I Street Name Cid Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY $TATEG._' ZIP 5 2-7' <br /> rz:E9 Z— <br /> PHONE#1 ' EXT• APN# LAND USE APPLICATION# <br /> (7/y) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR `� �/ / <br /> T/�7f'�' //� CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE� G�j 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 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA / ANAGER ❑ OTHER AUTHORIZED AGEN ENTJO %:G!, w y y�, y z.✓//�h G <br /> If APPLICANT is not the BILLINGPAR7'Y.proof of authorization to sign is required Title T <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: LA j2eTj�r-( r- PAYM E NT <br /> COMMENTS: RECEIVED <br /> JUN 2 8 2012 <br /> SAN JOAQUCN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � EMPLOYEE#: ( DATE: <br /> q0 Z� 2— <br /> ASSIGNED TO: d�' EMPLOYEE#: t ! DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: { P I E,,�_3 oy <br /> Fee Amount: ?31 <br /> Amount Paid Payment Date <br /> Payment Type Invoice# Check# L , Received B1q1.JJ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />