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SAN JOAQU40. COUNTY ENVIRONMENTAL HEALTt DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7 (,61- <br /> OWNER <br /> ,6iOWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> /v/% 0/ C4 -e <br /> SITE ADDRESS O , C/!SL3 U y <br /> A/"V�/ Street Number Direction " /`C Street a / Cit Z113 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /Gn S V r Street Number Street Name <br /> CITY i STATE; ZIPS/ -� <br /> _.i / °1, <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> �!r'I, <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 WS. <br /> APPLICANT'S SIGNATURE: E w / Gv'�t�C� DATE: � !t cy <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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: res vd [„�yLQ7.. M <br /> COMMENTS: WNT <br /> RErFWED <br /> JUL 2 4 2013 <br /> SAN JOAQUIN COUNTY <br /> NE ENVIROMENTAL, <br /> ACCEPTED BY: -�/yt i�� EMPLOYEE#: C 6 ATE: q 1 3 <br /> ASSIGNED TO: \ EMPLOYEE#: /'” 1-0 DATE: �/Z u /I <br /> Date Service Completed (if already completed): SERVICE CODE: ( , (_ P/E: ( ( /j 7> <br /> Fee Amount: 1 j , — -- Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />