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t SAN JOAQUUVLNTY EwmoNMENTAL HEALTH DWMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID# SERVICE REQUEST# <br /> ` ' y[ ��✓ 5paco fig 1 G <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACiIm NAME _ <br /> � '� <br /> -1 j,, <br /> SITE ADDREss ZIP calm <br /> _ �� 1 tem' �'"�' � � ��� <br /> Sheet Num r <br /> HOME or MAILnG ADDRESS (if Different from Saba Address) <br /> Street Number SUest Nam <br /> Cm STATE ZP <br /> PHONE#1 Exr, APH LAND USE APPLICATION tF <br /> 612 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR )A if L NG <br /> PHONE# Err. <br /> BUSINESS NAME,— I G„ <br /> HOME or MAIuNG ADDRESS F # <br /> L ( X51 <br /> CIT1f STATE LP e <br /> BILLING ACKNOWLEDGEMENT: L 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,StandZ .. <br /> STATE <br /> /and FEDE S. 1 <br /> APPLICANT'S SIGNATURE: 1/7)l_ DATE: l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER O OTHER AuTeoR=D AGENT= <br /> If APPLiCANT is not the B1L[M PARTY.proof of atttkorizadfon 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 environmentallsite 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. \t <br /> TYPES SERVICE REQUESTED: t'�ST � ��T 1VE RECEIVED <br /> COMMENTS: �EB 1 1� 111 FEB 1 2011 <br /> COUNTY <br /> 0310 141 P V- SAENV RONME ENVIRONMENTAL <br /> sp Ep SN Q paR-I Ov HEALTH DEPAR <br /> NE <br /> ACCEPTED BY: EMPLOYEE M `!oj DATE: , <br /> ASSIGNED TO: . <br /> EMPLOYEEM �( (� DATE: <br /> Date Service Completed (if already completed): <br /> �'YP1E:Fee Amount: (® OO Amount Paid (e j#C)_ SMMW10ECU0DE: <br /> Payment DateChe0 Payment Type Invoice# 1 <br /> EHD 4"2-025 ^ 1, ` SR FORM(Golden Rod) <br /> REVISED 11/17/2003 IX I �l I `� ?J b 1p , (�v C 9 pug�p�e,Vee- <br />