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SAN JOAQU ZOUNTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 a te, (o (4 �� <br /> OWNER/OPERA ror <br /> C C) ' r CHECK If BILLING ADDRESS <br /> FACILITY NAME�1� \pf _ l L�- V� -�� <br /> SITEE A—D�DRESS \ X� �r. � C)531-61 ( <br /> r) t ) Street Number I Direction I Street Name Ci Zip Code <br /> Ho,V—W MAILINGDRESS (If tff rent from Site A dress) JJ CSA M <br /> t r �(f�(,{ � �����J" v 1 Street Number Street Name <br /> CITY I V e rvr Q Y�-- 4 STATE ZIP <br /> PHONE#t t APN# \ LAND USE APPLICATION# r 1 <br /> (�0 �T <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <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 an FRDEJf�J R�L laws. <br /> p � � 3J �13 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ E)P 'I OR/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 environmentaUsite 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 /nLrn PAYMENT <br /> COMMENTS: RECEIVED <br /> c <br /> JAN 3 1 2013 <br /> SAN JOAQUIN <br /> ENVIROMEnTAL <br /> HEALTH I t <br /> ACCEPTED BY: =EMPLOYEE#: DATE: I <br /> ASSIGNED TO: _ EMPLOYEE#. DATE: <br /> Date Service Comp eted (if already Completed): SERVICE CODE: P I E: <br /> Fee Amount: 6d Amount Paid Payment Date 1 �� <br /> Payment Type Invoice# Check# / eceived By: PO <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />