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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t FR 00D_52!'0000 ('-;2-5 I <br /> OWNER/OPERATOR i CHECK if BILLING ADDRESS❑ <br /> r <br /> FACILITY NAME L <br /> SITE AD RESS rl / <br /> ] <br /> �eet Number Dih�tion I 1 St�e�et NamC(-e - Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#1 E.T• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ CHECK if BILLING ADDRESsig— <br /> BUSINESS NAME l/�� md <br /> PHONE EXT. <br /> '�,t� 1 i <br /> HOME or MAILING ADDRESSFAX# <br /> L95--�T LI c LaLm Dir, (-Zr)) '401--(fi42 <br /> CITY tl )I/) STATE 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 appl• a ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST Tq and FEDERAL law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PAR7Y,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 asit is available and at the same time it is <br /> provided to me or my representative.. 9 <br /> TYPE OF SERVICE REQUESTED: v F7AYMENT <br /> COMMENTS: REULIVIZILi <br /> MAY 16 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed Kakeady completed): SERVICE CODE: PIE: <br /> Fee Amount: -7D <br /> Amount Paid 3 `D� Payment Dae 56 b !✓ <br /> Payment Type Invoice# Check# ( ,5"5—F) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />