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SAN JOAQ16 COUNTY ENVIRONMENTAL HEALI*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP OR' <br /> \ � _ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �, T <br /> t Direction trMet .tuber <br /> H,oE o M ADD ES (f Different from Site Address) <br /> Street Numbers Street Name <br /> Q7n flL� <br /> ONE#1 / ExT• APN# LAND USE APPLICATION# <br /> il) ko LPE <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ( CHECK If BILLING ADDRESS <br /> BUSINESS NA � <br /> <br /> <br /> <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 usmess as ide 'feed on this form. <br /> I also certify that I have prepared thiap licatton a d t6ILthew rk tobe performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar S T an ED w . <br /> APPLICANT'S SIGNATURE: DATE: VA <br /> PROPERTY/BUSINESS OWNER_ O RATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILL1NGPARTY,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 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 availalte time it is <br /> provided to me or my representative. Cry, <br /> ECEIVED <br /> TYPE OF SERVICE REQUESTED: /ly '� CcT�'��i-' 104A 0 4 2014 <br /> COMMENTS: �j� ��./ <br /> , <br /> � v — L IN CO <br /> NVIR MENTAL <br /> HEALTH D PARTMEIYI' <br /> ACCEPTED BY: !1 fpm EMPLOYEE#: DATE: LC t <br /> ASSIGNED TO: r 1 EMPLOYEE#: QL DATE: ! j <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P I E: l� D <br /> Fee Amount: a Amount Paid — Payment Date Gil <br /> Payment Type ( Invoice# Chec'k# Received By: <br /> EHD 48-02-025 l �JYJ� v SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />