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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#OWNER <br /> 21pm CHECK if BILLINGADDRESSO <br /> FAcIu,NAME <br /> SITE ADDRESS 1 <br /> 3 �u L ,�'r/ti <br /> Street Number I Dir"tion Street Name <br /> HOME or ILING ADDRESS (if Different from Site d ) <br /> Street Number <br /> Street Name <br /> CITY STATE zip <br /> r <br /> Pr <br /> PE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. LOCATION DE <br /> CONTRACTOR/ S I E <br /> REQUESTOR <br /> \ ?,*Ot g„��+ CHECK if BILLING ADDRESS <br /> BUSINESS fVAME fl�t��� `�h y. ExT. <br /> HOME or MAILING ADDRESS O�k J\tSIX61 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 HFALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to he performed will be done in accordance with all SAN JOAQtJIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE/: . �ig !C(/to°'Q A!_ l�f 1`ti+ DATE: !�: -/:2- —01 <br /> PROPERTY/BUSINESS OWNEREI OPERATOR/MANAGER ❑ OTHER At AGBFT❑ <br /> lJ,aPPLICANT is not the BILLING PARa 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 JO.AQUIN COUNTY ENVIRONMF.NTAI.HFAI_Tti DLPARTMENT 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: <br /> � <br /> COMMENTS: - <br /> c F;>_ Q <br /> DEC 12 2011 <br /> ACCEPTED BY: ZW Id EMPLOYEE#:- ATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date lalIZ- P <br /> Payment Type Invoice Al Check# Recelved By: <br /> 1%W1 EHD <br /> SR FORM(GLn*Rod) <br /> REVISED 11/17/2003 -6") 7 -ra _S�wr--PU <br />