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f' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHSPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J Qc-) 3 Z <br /> OWNER/OPERAT <br /> r ����I✓��� r-^Q � \`� �` CHECK If BILLING ADDRESS <br /> 1 r <br /> FACILITY NAMEi`r <br /> JaA <br /> SIT DDRESS V � r,N� � � �/��•J,,',��►��� ��;� r <br /> Street Number Direction �—"•ry•!' <br /> A/^t N Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> C, <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1pt ,^_- <br /> CHECK If BILLING ADDRES <br /> B NESS N E PHONE# EXT' <br /> '�`�� 44 0c 6990 <br /> HOM Or MAILING AD ESS F # <br /> 4c. -Z (%-) <br /> CITY STATE CA ZIP C <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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. <br /> TYPE OF SERVICE REQUESTED: SV O <br /> COMMENTS: P E(3'#EP1F–®- <br /> OCT 2 3 2013 <br /> SAN JOAQUIN COUNTY <br /> HEALVI <br /> TH DEPARTM <br /> ff <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 0 <br /> Date Service Completed (If already completed): SERVICE CODE: c5.5 PIE:(„i �1 7 <br /> Fee Amount: Amount Paid — Payment Date (� <br /> Payment Type Invoice# Check# Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />