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SAN JOAQU*OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> Wei <br /> FACILITY ID# SERVICE REQUEST# <br /> p �j 10 S <br /> OWNER/OPERATORCHECK if BILLING ADDRESS❑ <br /> ��12U oil Go . ' 1 u v <br /> FACILITY NAME <br /> SITE ADDRESS3515 NQYy Drive S-rocKfion g132 U3 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EZT' APN# LAND USE APPLICATION# <br /> (quo) l I - 0011 1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( IW) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> T I PHONE# En. <br /> BUSINESS NAME Y O (114) <br /> HOME or MAILING ADDRESS FAX# <br /> a t e c <br /> a-1) <br /> CITY STATE A 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 <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: Q DATE: 1OT4 12-012 <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT` <br /> /,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 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: <br /> COMMENTS: RECEIVED <br /> � OCT 252012 <br /> SAM,IoAQUPI COUNTY ' <br /> r�TMDEPEXTAL <br /> ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ATE: (y <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Q <br /> Fee Amount: / Amount Pak& Payment Date IP /)` <br /> Payment Type Invoice# Check# R ceive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />