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SAN JOAQUWOUNTY ENVIRONMENTAL HEALD*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ' / <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> i'�resa���-• I��,-�t� <br /> SITE ADDRESS <br /> 3 Street NumbeNaQme Ci i,—Code <br /> c (-"7 0 W <br /> dgl <br /> HOME or MAIUNG A7W_v'- (_ <br /> ESSS (If Different from S' Address) <br /> L 4L- Street Number Street Name <br /> CITY STATE ZIP C�4 2 1_ _7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> '77 - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR tl <br /> REQUESTO <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> P �L —`7 <br /> HOME or MAILING ESS < FAX# <br /> CITY , STATE /1_ 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 FEDEPAL aws. <br /> APPLICANT'S SIGNATURE: DATE: /A 5 <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT 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. /��/rn� <br /> TYPE OF SERVICE REQUESTED: �d- Cw PAYMENT <br /> Iii ENT <br /> COMMENTS: RECEIVED <br /> JAN 12 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: z Z P1 E: 4.10 Z <br /> Fee Amount: Z��j Amount PaidO Payment Date 15 <br /> Payment Type Invoice# Check# Received By: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />