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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 000 Z31 Y, 6(� 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Slraeumber pirec[ion Street Name J Zip Corte <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> I ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> [REQUESTOR - R1cK Lin CHECK If BILLING ADDRESSUSINESS NAME VT r PHONE# OXTME Or MAILING ADDRESS J FA%#f5G Gi la AwC/ PR/ve,TY STATE Com/ 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 /> 1 also certify that I have prepared this application and tl t e work to be performed will be done in accordance with all SAN JOAQUIN - <br /> COUNTY Ordinance Codes,Standards, STATE and FE ws. <br /> APPLICANT'S SIGNATURE: - DATE: I� _ <br /> PROPERTY/BUSINESS OWNER OPERATOR/Aw. ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT 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. --(nI <br /> TYPE OF SERVICE REQUESTED: fl("! l.L� I ev\ PAYMENT <br /> COMMENTS: RECEIVED <br /> C4 MAR 4 2011 <br /> 3_ I, �_ ( 1 SAN N COUNTY <br /> ENVIRONVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: CSS 1 DATE: <br /> ASSIGNED TO: EMPLOYEE#: l DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE. <br /> Fee Amount: Amount Paid Payment Date 3/;y- <br /> Payment Type Invoice# Check# / Received By:(A, <br /> EHD 48-02-025 SR FORM(Golden Rod) , <br /> REVISED II/17/2003 �vb, 3Lt � �,{ ' C.�xrr-IntS� <br /> 2 <br />