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SAN JOAQUIN COUNTY I'NN'IRONN1ENTAL HEALTH DEPARTMENT <br /> SERVICE RI+QUEST <br /> Type of Business or Property FACILITY ID!:::] SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSL A^J r-- s l0 LIG, t O-Jt��09 <br /> w N,Rsrtrh��� <br /> 7. 5 Street Number[ Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (Zo°t 1 Q7b . oSoz. a? S - $7-4-3451 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> CRM A ctrl tT t 5 <br /> 4-5v <br /> f 11 <br /> HOME Or MAILING ADDRESS FAX# <br /> 0 1.V ( 116 )x-51- /boo <br /> CITY AG P M STATE CA ZIP 9581 <br /> �� O JG <br /> BILLING ACKNOWLEDGEMENT: 1, 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 app ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard S TE a FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: O2 -0 7 - I Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORI\'IATION: 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: t0 PAYMENT <br /> COMMENTS: <br /> -- -- FEB 0 9 2012 <br /> SAN JOAQUPN CDU <br /> t — ENVIRONMENTAL <br /> HEALTH r)EPAF?7MEW <br /> ACCEPTED BY: EMPLOYEE#: r,.� DATE: /Z <br /> ASSIGNED TO: EMPLOYEE#: v 1�� DATE: <br /> Date Service Com le ed (if already comple �: SERVICE CODE: �J/ P/E: p <br /> Fee Amount: I l� �� Amount Paid ���� D Payment Date �— G ! a— <br /> Payment Type L/ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />