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• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropeU FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ' <br /> f1,./a ` � CHECK((BILLING ADDRESS <br /> FACILITY NAME y �� <br /> SITEADDRESS .3 s <br /> re Name Cit Zi CoticStreet Nua vet � <br /> HOME or MAILING ADDRESS (If Different from Site Addres ) r (f/1/I ` <br /> Street Number I_lQAA S rf eel Name <br /> CITY STATE ZIP G <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# C <br /> 1ZD <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // CHECK if BILLING ADDRESS <br /> tr/G2 Z <br /> BUSINESS NAME _/ PHONE# EXT. <br /> lJ� c��IZ TJn�ea �PLnZcy Za9 ^7S3 879 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 1__Gro STATEG^d <br /> zip <br /> D <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 T E and FERE /I <br /> APPLICANT'S SIGNATURE DATE: 3/Z y/1) <br /> PROPERTY/BUSINESS OWNER 13 <br /> PE TOR/MANAGER OTHER AUTHORIZED AGENT <br /> I,fAPPLICANT 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 t0 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: P <br /> COMMENTS: PYECEIVED <br /> SAN 2 4 2011 <br /> MENVIAOUI COUNTY <br /> �TMR EPgpTME <br /> ACCEPTED BY: EMPLOYEE#: 7 DATE: <br /> ASSIGNED TO: JA EMPLOYEE#: Z DATE: <br /> Date Service Completed (ifre dy completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date l <br /> Payment Type Invoice# Cltack# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />