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RUSHN JOAA COUNTY ENVIRONMENTAL HEALTHHAPARTME <br /> SERVICE REQUEST <br /> Type of Busi as or Pro ID erty FACILITYSERVICE REQUES # <br /> OWNER/O RATOR �!) <br /> CHECK if BILUNG ADDRESS 0 <br /> FACILITY NAME - <br /> SITE ADDRESS � � L�'J <br /> 511'betAumu� 0 rection m ��/pCl <br /> HOME Or MAILING ADDRESS (if DNferent from Site Address) zf code <br /> Street Number Street Name <br /> CITY <br /> STATE LP <br /> PHONE#1 APN It LAND USE APPLICATION# <br /> PHONE#2 Exr. <br /> BOS DISTRICT LOCATION CODE <br /> -- ONTRACTOR/-SERVICE REQUESTOR <br /> REQUESTOR - <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE EXT. <br /> ( -0/ a <br /> HOME Or MAILING DRESSY jai FA%# �J� <br /> .CITY <br /> STATE -k2APt!�'t� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, op <br /> acknowledge that all site and/or project specierator or authorized agent of same, <br /> fic 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 ap <br /> ATE <br /> I' ation and that the work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standards and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ ' OTHERAUTHORIZEDAGENT14-. <br /> IfAPPLICANT is not the B77d.1NGPAR7T proof of authorization to sign is requiredf 1, 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 environmentaUsite 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: 1 62 �jj T <br /> COMMENrs: p <br /> JUN 2 8 11 <br /> SAN JOAQUIN C UNTY <br /> HEALTH DEPAR ENT <br /> ACCEPTED BY: W� EMPLOYEE#: DATE: (P <br /> ASSIGNED TO: Y' IBJ <br /> EMPLOYEE#: 7-W DATE: <br /> Date Service Completed (if already completed): .SERVICE CODE: 90 P I E: <br /> Fee Amount: 00 Amount Paid J 1 b Q Payment Date -Wt( <br /> Payment Type Invoice# Check# .ter <br /> ',S(�3'—] Received By: N"- <br /> EHD 48-02-025 <br /> REVISED 17/17/2003R ■ ■�� SR FORM(Golden Rod) <br /> Ui <br /> � 1 <br /> I : <br />