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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> • SERVICE REQUEST • <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> TM <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSc{ <br /> 22-2 S m�'K1t N� J S�C7�TO C1 bQ <br /> Street Number Direction /` treet Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I�1 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT! APN# LAND USE APPLICATION# <br /> (209 ) ztap - t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME ' PH E665-1 . <br /> HOME or MAILING ADDRESS FAX# <br /> CITYSTATE 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 or <br /> 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: > k kf—j DATE: I 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required —� 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 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: US:-r "-7V-�o rt-7 <br /> COMMENTS: RECEIVED <br /> AUG 12 2011 <br /> SAN JOAOU(N COUNTY <br /> ENVIROlgMENTAL <br /> HEALTH CcpAFRT1vI L <br /> NT <br /> ACCEPTED BY: L � EMPLOYEE#: jJ3L( DATE: Wf-,> It/ <br /> ASSIGNED TO: EMPLOYEE#: 2 DATE: K-//2JV <br /> Date Service Completed (if already completed): SERVICE CODE: (Cr P I E: =Z3&p <br /> Fee Amount: Z S'. U%) Amount Paid ��� Payment Date 8 (I;-) I ( <br /> Payment Type V/ Invoice# Check# (Q'15 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />