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SAN JOAQ,,—i COUNTY ENVIRONMENTAL MALI— DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (Afts s4a:�"Vq ,� i y .1 i),(, (�(: / S�I skIco & 9 9 e.) / <br /> OWNER 1 OPERATOR 61 LAV Me ^ <br /> C <br /> S * ftS CHECK If BILLING ADDRESS <br /> �JCn <br /> FACILITY NAME ' 1, , S <br /> SITE ADDRESS (�� "A f'v w\ C K s <br /> 2 Street Number Direction T') ,\1QAeet Name Citv ZW Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) C y� C��'e� c 1 y <br /> Street Number / Street Name <br /> CITY /� ��� STATE ZIP <br /> \V O <br /> PHONE#1 E,. APN# LAND USE APPLICATION# <br /> 7 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <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 ENvntoNMENTAL 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAJVT is not the BiLLINGPARTY,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. <br /> TYPE OF SERVICE REQUESTED: !�'C� <br /> COMMENTS: PA MENT <br /> n ,,YLA-,- ( � RECEIVED <br /> JUN 092014 <br /> SAN JOAQUIN COUN <br /> ENVIROMENTAL <br /> ACCEPTED BY: L,% f���)L� EMPLOYEE#: �_ 7L1 DAT I// <br /> ASSIGNED TO: ^ EMPLOYEE#: DATE: <br /> Il,E- f f <br /> Date Service Completed (if already completed): SERVICE CODE: �* PIE: <br /> Fee Amount: ��ZS Amount Paid "zS,0o Payment Date ;l �+. <br /> Payment Type Invoice# Check# Received By: > <br /> EHD 48-02-025 ?,C)� SR FORM(Golden Rod) <br /> � �� <br /> REVISED 11/17/2003 S <br /> oo('09 80 1 <br />