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SAN JOAQOCOUNTY ENVIRONMENTAL HEALSEPARTMENT <br /> SERVICE REQUEST <br /> Type A Business or Property FACILITY ID# SERVICE REQUEST# <br /> -}- 6 <br /> OWNER/OPERATOR <br /> i4vk <br /> CHECK If BILLING ADDRES <br /> I - � <br /> FACILITY NAME _ <br /> �o <br /> IL 4tu A/-e-- <br /> C4 <br /> SITE ADDRESS 49A, <br /> //f)t//�,/JStr!ember Direction eefNafne CI Zin Code <br /> HOME Or MAI A DRESS (If Differ t from Site Address) <br /> atiAoA111) Street Number Street Name <br /> CITY STAT ZIP <br /> M <br /> 2 EXT. APN# LAND USE APPLICATION# <br /> Z[2 <br /> PHONE#2 EXT. BOS DISTRICT / LOCATION CODE <br /> ( ) N <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 proje <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 JOAQ <br /> COUNTY Ordinance Codes,Standards,STATE andF DERAL 1�fw"�S. <br /> 7/��)Z* <br /> APPLICANT'S SIGNATURE: V/ LDATE: <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, 1,the owner or operator of the property located at th <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: 60 C <br /> COMMENTS: U <br /> RECEIVED <br /> H--3 2 0 2013 <br /> SAN JOAQUIN COUNTY <br /> INVIRO ENT L. <br /> ACCEPTED BY: EMPLOYEE 9T <br /> ASSIGNED TO: f�J EMPLOYEE#: DATE:U LA <br /> Z(7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: A1103 <br /> Fee Amount: �? !r`� Amount Paid Payment Date <br /> Payment Type Invoice# Check# R ceived By: <br /> EHD 48-02-0258 o2p 70 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />