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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR �t <br /> �Q f T�D a.S S G+r1 CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SRE ADDRESS 1 O ZGt / �L + j`�a /_ 7 (�4LJ/0 ; <br /> C Siroet Number pirecbon Strxl Name C a Zi'.JCode7 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Slieel Number freer Name <br /> CITY STATE ZIP <br /> PIIONE#1 E". APNItoQf LAND USE APPLICATION <br /> I G�31 <br /> ;i <br /> PHONE#2 E'N. SOS DISTRICT LOCATIONC/� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR _ {, <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# E <br /> 3 V <br /> HOME or MAILING ADDRESS � C ZZ FAX# <br /> Z t <br /> CITY -v/Y 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 /> 1 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,Standard-r, TE and FEDERAL laws. <br /> ar / <br /> APPLICANT'S SIGNATURE•. z_,/ DATE- <br /> PROPERTY/BUSINESS OWNER ELI-, OPEP�ERATO^R 7.ANAr,ER ❑ OTFIER AUTHORIZED AGENT❑ <br /> UAPPLICAXT is not the(JIGGING PARTY proof of authorization to sign is required Title <br /> AUT11ORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the properly 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: <br /> COMMENTS: nn t <br /> C-e r o v-h w�-� ��i_�s m.,s,c-v. �Q CT1Yci✓ty c�z t'>7 �G 2 'n�J1Y�rt¢?kTt1t r�i') <br /> y � 'n __ RECEIVED <br /> Sj >Lr c y��""� <br /> APR 2 6 2012 I <br /> MAS Jo QUM GC Hit' A <br /> /' M.,y ROHM AL <br /> ACCEPTED BY: - f EMPLOYEE#; � (� uAiF",D L <br /> ASSIGNED TO: !� .EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): V SERVICE CODE/ PIE: Z!I Z <br /> Fee Amount: If - Amount Paid . Payment Date Il <br /> Payment TypeInvoice# Check# Received B i4l, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1772003 <br />