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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />i SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERk1ICE REQUEST # <br />It � <br />`3iZz- <br />(3(' <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />( 201 <br />FACILITY NAME <br />SITE ADDRESS ��� 3 , ir1 �,j \ 1 (��� cx:� q �3 <br />U 1 <br />Street Number Direction <br />Street Name cityp Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />jU <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />on . - <br />PHONE #1 EXT. <br />APN # <br />EMPLOYEE #:L7 <br />LAND USE APPLICATION # <br />(9c'0 CO 2 ^ cf-�1&2 <br />ASSIGNE <br />�/.�Y�/\ <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING G ADDRESS <br />BUSINESS NAMEr <br />PH C)A) <br />- EXT, <br />HOME Or MAILING ADDRESS <br />FAX# <br />-%Q1- <br />z� <br />( 201 <br />CITY Ytlw STATE ZIP <br />OCT - 7 2011 <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 />r <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required `1 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 />EHD 48-02-025 SR FORM "(Golden Rod) <br />REVISED 11/17/2003 <br />! <br />PAY <br />TYPE OF SERVICE REQUESTED: <br />RE In rniy ED <br />COMMENTS: <br />OCT - 7 2011 <br />SAN JOAQUSN couNTY <br />ENVIROHMEN7AL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:L7 <br />DATE: f�y G <br />ll <br />ASSIGNE <br />�/.�Y�/\ <br />EMPLOYEE #:DATE:AAA 64Y <br />Date Service Co p eted <br />if already completed): <br />SERVICE CODE: - <br />P 1 E: 2�b <br />Fee Amount: 3'7 <br />C'"'' <br />Amount Paid <br />3`1S D <br />Payment Date D <br />Payment Type <br />Invoice # <br />Check # �2 <br />Received By: <br />EHD 48-02-025 SR FORM "(Golden Rod) <br />REVISED 11/17/2003 <br />