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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# $ERV ICE REQUEST# <br /> WN /OP RATOR I/`/UAU`7iJ5 <br /> CHECK If BILLING ADDRESS <br /> FCILITY N ME <br /> RE ADD ESS <br /> IStreat Number G�ectlon �/ Street Name VV' Code I <br /> HOME or MAI LIN ADDRESS If Different from Site Address) <br /> 1 Street Number Street Name <br /> CITY STATE ZIP <br /> CA <br /> PHONE#1 N# LAND USE APPLICATION# <br /> PHONE#2 EKT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE STOR <br /> C J` CHECK If BILLING ADDRESS <br /> BUSINESS NAME (� PHONE# EM• <br /> wl ( ) <br /> HOME Or MAILING ADDRESS FAx# <br /> ( ) <br /> CIN G S,T E 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 laws. <br /> APPLICANT'S SIGNATURE: — <br /> DATE:oV 55�2� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ffAPPLICAM'is not the B/LLBVG 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 thGlrK'y130.Yu'iPi[is:• <br /> provided to me or my representative. 1'Mi IY E � <br /> RECEIV <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: APR 2012 <br /> SAN JOAQUIN COL NTY <br /> ENVIRONMENT <br /> nq HEALTH DEPAR NT <br /> ACCEPTED BY:La <br /> EMPLOYEE M /A DATE: ZS <br /> ASSIGNED TO: (AMA(U <br /> EMPLOYEE M __11.. DATE: <br /> Date Service Completed (if already completed): SERVICECOOE: oul PIE:ILf <br /> Fee Amount: 7 �'Qu Amount Paid IP1 5 a Payment Date < o �Z <br /> Payment Type S' Invoice# k# y a V V y y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />