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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ID 0 L) CHECK It BILLING ADDRESS <br /> FACILITY NAME S ), TV` ` 6Q Q l Z mos SO-9 <br /> SITE ADDRESS . / 2- CS Q k cc V L FS AV C "f}tJ=—'Z4 q r3 3Z <br /> Street Number Direction Street Name cit Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t_{.JVtSP /Yl/Q L-RT1+1`2-O treet Number CA Street Name a S--73 <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> avT 6 o k - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If=BILLING <br /> BUSINESS NAME <br /> PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12- O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 /> infom]ation 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: C��'L 0 l'"N <br /> COMMENTS: <br /> ENT- <br /> o � RECEIVED <br /> DEC 17 2010 <br /> SA ENv RONMENTALCOUNTM <br /> HEAL-T1't DEPARTME� <br /> ACCEPTED BY: - EMPLOYEE M DATE:C � d <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q C-0 PIE: <br /> Fee Amount: �/ 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 />