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SAN JOAOCU COUNTY ENVIRONMENTAL HEALTO DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME / _ t' <br /> SITE ADDRESS (077 VI2-H cert <br /> 9beet Number DI I am <br /> H ME Or MAILING ADDR SS If Different from Site Address) <br /> Street Number Street Name <br /> CI STATE ZIP <br /> 3 <br /> PHONE#1 Ems' APN# LAND USE APPLICATION# <br /> PHONE#2T BOS DISTRICT LOCA NCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REDUESTOR"{ ;w-D CHECK If BILLING A� <br /> BUSINESS NAME 7/� PH NE# <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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. , e� <br /> APPLICANT'S SIGNATURE: '0 e4hg �j, DATE: 011 ( 13, <br /> PROPERTY/BUSDVEss OWNER❑ OPERATOR/MANAGER OTHERAUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tine <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. h n ) . <br /> TYPE OF SERVICE REQUESTED: D v b QNN s u 1 4-A 1 !/�IV <br /> COMMENTS: <br /> SEP 2 5 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> IjEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 9-7/ 7 <br /> DATE• ZS 13 <br /> ASSIGNED TO: / r y I f \ EMPLOYEE#: DATE: 63,13-5,11-T <br /> Date Service Completed (If already completed): eft — SERVICE CODE: I P)E: b <br /> Fee Amount: Amount Paid Payment VVDate <br /> Payment Type Invoice# Check# 1/yL�( c Received By: <br /> EHD 48-02-025 '' ''` 1'u'"�L-Uti� L " �G SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />