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SAN JOAQUL, —JUNTY ENVIRONMENTAL HEALTH _.ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> � / CHECK If BILLING ADDRESS El <br /> FACILITY NAM r <br /> SITE ADDRESS "'7 �-2 S (4tL -lr`��1,� _ , <br /> �'Street Num er Direction Street'Nam (��CCCit// ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Sit dd//less) <br /> CStreet Number Street Name <br /> Clp� / STATE ZLilaIP 25 2G <br /> PHccccO__NNE__#1 EXT. APN# LAND USE APPLICATION# <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: 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 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 ERATOR/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 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' PAYMENT <br /> COMMENTS: <br /> AUG 2 3 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED EMPLOYEE M DATE: <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J P I E: <br /> 2- <br /> Fee <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />