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SAN JOAQW, 0UNTY ENVIRONMENTAL HEALT&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 � �1.�—�- �j✓✓� '�g n�.e��j�r <br /> SITE ADDRESS <br /> uo Street NumberDirection Street Name it Zip Code <br /> <br /> <br /> <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 151c�) <br /> --756 — 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ✓i 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 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 an he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE 1� EKAJ. aw <br /> APPLICANT'S SIGNATURE: DATE: 2&71/3 <br /> PROPERTY/BUSINESS OWNER PERATOR/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, 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. <br /> TYPE OF SERVICE REQUESTED: RANUENT <br /> COMMENTS: RECEIVED <br /> APR 04 2013 <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: P I E: O <br /> (_ <br /> Fee Amount: CJ Amount Paid __ Payment ate .�flJ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />