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SAN JOAQUIN COUNTI' ENVIRONAIENTALHEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />T V, �c p <br />FACILITY ID # <br />�3� <br />SERVICE REQUEST # <br />5400 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS E] <br />FACI <br />V^TI\1}x-r't- <br />1nI�- ����(�� <br />SITE AoDR -StlrJee/l NlQlrmber <br />D^ire``ct`ioOL- <br />n <br />%-/`-�(-�J <br />r�J�",/q/glr/e�/e(CRame <br />STAT /11 ZIP /Il <br />��e�✓©/y'/�, <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street rJumber <br />SAN JOAQUIN COUNTY <br />Siree[ Name <br />CITY <br />STATE Zip <br />PHONE #i Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />DAT6 <br />/ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE0TTFCT0V <br />REQUESTO <br />CHECK if BILLING ADDRESS•• <br />BUSINESS NI�/A-4/ / <br />Exr. <br />HOME Or MAI ING R���/a <br />12 <br />PA%# <br />CITY S._ <br />STAT /11 ZIP /Il <br />BILLING ACKNOWLEDGEA'IFNT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/o1project Specific ENVIRONMENTAL HEALTH DEPARTNIEN'P llourly Charges associated with this project <br />or activity will be billed to tie 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, Srandar'd/s TE and, FE�DEjRA4, laws. <br />APPLICANT'S SIGNATURE: A� 7r✓'pCr\< � DATE: 56YA7 <br />PROPERTY I BUSINESS Oxx'NER❑ OPERATOR/MANAGEOj OTHER AUTHORIZED AGENT❑ <br />IJAPPLICANT is not the BILLING PAR71' 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same fire it Is <br />provided to Ine or my representative. <br />TYPE OF SERVICE REQUESTED: <br />V6 <br />PAYMENT <br />COMMENTS: / <br />12 <br />W+V i L <br />AUG - 9 2011 <br />SAN JOAQUIN COUNTY <br />-�{{y�f• <br />' ��dd <br />S�L� 017 <br />HE LTH DEPARTMENT <br />ACCEPTED BY:: <br />EMPLOYEE <br />DAT6 <br />/ <br />ASSIGNED TO:qb <br />V J <br />EMPLOYEE#: i `�' <br />DATE: <br />Date Se"ice Completed (i( already completed): <br />SERVICE CODE: <br />P I <br />Fee Amount: U OG Amount Paid <br />1E ago. O� Payment Date/I /`/ <br />Payment Type ✓ <br />Invoice# <br />Check# 6 <br />�.gg� <br />r f /J /1 <br />Received By: t•Z/` <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />