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SAN JOA(` N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2-,0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME II�VJI��� *- i432— (i432— ( <br /> SITE ADDRESS � -� k; — <br /> Z S1- O <br /> Street Number Direction Street Name Cit Zi Co e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY Ci STATE zip ( S-0 j <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ( (� <br /> PHONE#2 EXT• BOS DISTRICT / LOCATION CODE <br /> Iv) S � 3 �.j C (-+l <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 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 la ssj. `� <br /> APPLICANT'S SIGNATURE: �(1,d ",� " ' l ay 5 ( ,J C DATE: 2 ^� _0 <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, 1, 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: (VQ,-\1 Z&,u L d'L 14 PAYMENT <br /> COMMENTS: <br /> FEB - 4 2012 <br /> SA ENV RONME BENT <br /> HATH DEPAR <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: t h►1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , PIE: ( C�Z <br /> Fee Amount: ( Z � Amount Paid Payment Date / /3 7y <br /> Payment Type yK c Invoice# Check# Received By: <br /> r C1. 3�. <br /> EHD 48-02-025 � SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />