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SAIISOAQUI&OUNTY ENVIRONMENTAL OALTH &ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Poperty FACILITY ID# SERVICE REQUEST# <br /> 0 ,*J SkC,OT7 <br /> OWNER PERATOR <br /> CHECK If BILLING ADORES <br /> Ile- <br /> FACILITY NAME <br /> SITE ADDRES ZI <br /> Street Number Direction (. tree[NaiRe ' CifCode <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• BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HMEPP`o`r AILING ADDRESS !� FAX# <br /> (V 4. ( ) G) <br /> CITY / STATE ZIP � <br /> BILLING ACKNOL—WLEDGEMENT: 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 projeEt or <br /> activity will be billed to me or my business as identified on this form. ­' <br /> orm. 114 Y41 <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN Jo <br /> COUNTY Ordinance Codes, Standards STATE and FEDERAL laws. <br /> C <br /> .ff ;V � <br /> APPLICANT'S SIGNATURE: •� ��jth S 1� <br /> �" DATE: 0 <br /> 7 !� <br /> PROPERTY I BUSINESS OWNER 0 �PERATORf, <br /> /MANAGER ❑ OTHER AUTHORIZED AGENT L9 E/�/1'44, Q(J/u <br /> /f APPLICANT is n0 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 abdVd?V NT <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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: �� I l� <br /> COMMENTS'a C-l'T JJ IC ( 4'v�l �S�- 1` S�V/ tial 7 / t C <br /> c4.11 dOPkJ SUN <br /> 5 2011 <br /> 6v 1,\4 <br /> "Vi r""L <br /> PERMIRScRI 4'. <br /> ACCEPTED BY: EMPLOYEE#: DATE: C <br /> ASSIGNED TO: IPPI EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P/E: .Z CJ <br /> Fee Amount: ' '(-' Amount PaIr 'h 7 Payment Date (o <br /> Payment Type Invoice# Check# Si�3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />