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SAN JOAQUL 2OUNTY ENVIRONMENTAL HEALTF: -'PARTMENT <br /> C-5IZ, Y,ICE REQUEST <br /> Type of Business or Property FACILITY ID# �SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> / — U ,'L L CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS CV <br /> Street Number Direction Street Name CI Zip Code <br /> HOME or MAILING AADDRESSS� (If Different from Site Address) i got <br /> s- 1Iq- l Street Number Street Name <br /> CITY . STATEZIP `' <br /> �h /6f <br /> PHONE#1 ExT• APN# r LAND USE APPLICATION# <br /> ( <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME ExT. <br /> � ` "� PH N I 45 1 is <br /> HOME Or MAILING ADDRESS\ FAx# <br /> ) <br /> CITY r r n STATE 69 ZIP G <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 th s appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s,STA E and F E L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not ILLING PARTY,proof of authorization to sign is required�y Title <br /> AUTHORIZATION TO RELE E 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 ai iy¢ Ale lime It is <br /> provided to me or my representative. ` ''�IIS NT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENT' SAN JOA <br /> QUIN RECEIVED ENVIIOMEN UNTy <br /> RUSH HEALTH UEPAI�TMENT <br /> MAR 13 2013 <br /> SAN JOAOUIN COUNTY <br /> ACCEPTED BY: HEALTHLkIWNT DATE: <br /> ASSIGNED TO: l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S P 1 E: a <br /> Fee Amount: J � Amount Paid 37S� f/g7 v0Payment ate 3/ /3 13 <br /> Payment Type Invoice# Check# liY7 Received By����Cp <br /> EHD 48-02-025 C! <6'± SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />