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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT"EPARTMENT <br /> �. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> tcx- oo W 7-3 620069 <br /> OWNER t OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME f <br /> SITE ADDRESS C'� IFL �'�S �/� f r�r✓TCG ��Z <br /> Street Number Direction Street NameCi <br /> HOME or MAILING ADDRESS (If Different from Site Address) b 6 <br /> Street Number Street Name / <br /> CITY /r STAT falu ZIP ©I�l <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 7 CHECK If BILLING ADDRESS <br /> BUSINESS NAMAEPHONE# EXT. <br /> 13 r t bz-e-a 17w-rS r- - ;t - <br /> HOME or MAILING ADDRESS FAx# <br /> CITY S 7 ZIP `�e'� <br /> X13 tM�-rl?I� <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 or <br /> 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 ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Standardofl <br /> TE and FEDERAL 1 s. <br /> APPLICANT'S SIGNATURE: ` DATE: /02 / 110 d <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAACER ❑ OTHER AUTHORIZED AGENT <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 ENVIRONMLNI'AL 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: C �LNT <br /> COMMENTS: DEC <br /> 14 2010 <br /> -AN <br /> E V1F?OfVMEOpUNTy <br /> ACCEPTED BY: EMPLOYEE#: DATED <br /> ASSIGNED TO: EMPLOYEE#: J J+ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: r' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />