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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 5 FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> (� e—rrv'De't <br /> SITE ADDRESS �j�-'�'✓ I�, f+�/� s�^[r� :l 6 la 5,>-Z A 7 <br /> Street Number Direction / Street Name city t Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME ,CPHONE# ExT•e- ��"• �C; -;ve-1 ?-7�`�-7P� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S c;—/—d STATE �^ry 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 la <br /> APPLICANT'S SIGNATURE: DATE: �`� <br /> PROPERTY/BUSINESS OWNER❑ OPE AGER ❑ OTHERAUTHORIZEDAGEN <br /> If APPLICANT 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: S� PAYMENT <br /> COMMENTS: REeEfVEu <br /> SEP 2 s 2012 <br /> sw JOAQM C00,4Ty <br /> EWRONka(THEALTH D IN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 17 <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E:2 <br /> Fee Amount: Amount Paid Payment Date at <br /> Payment Type L ( Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />