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SAN JOAQUIR COUNTY ENVIRONMENTAL HEALTH LYEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOKP <br /> L(:— CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /_� <br /> T Street Number :L)-! <br /> Zf CoUe <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECKlf BILLINGADDRES <br /> BU ES E ) � /� �� � PHONE# €xr. <br /> HOME or MAILING ADDRESS FAX# 17) <br /> CITY +��'+�. li. STATE <br /> Gq 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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,S TE a FEDERAL laws. p <br /> APPLICANT'S SIGNATUR <br /> PROPERTY I BUSINESS OWNER❑ OPERATO ER OTH AUTHORIZED AGENT "C IfAPPLICANT is not the 8r�crn e PARTy,proof of autho ation to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: PAYM2 ENT <br /> COMMENTS: IRECEIVEO <br /> FEB 13 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> uF:ALTH DEPAWMew <br /> ACCEPTED BY: 1 EMPLOYEE#: zb/ ?U DATE: <br /> As SIGNED TO: /` f� - C� EMPLOYEE#: !( 7� if DATE: <br /> Date Service Completed if already completed): SERVICE CODE: 0 3 4- PIE: <br /> Fee Amount: 4-7 �- Amount Paid Payment Date <br /> Payment Type Check# Re eived By/ <br /> Invoice# <br /> EHD 48-02-025 SR FORM{Golden Rad} <br /> 07117108 <br />