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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br />' <br /> Type of 5usiness or Property FACILITY ID# SERVICE REQUEST# <br /> /,r <br /> F <br /> OWNE6 IOPERATOR CHECK if BILLING ADDRESS <br /> FACILITY 14AME <br /> SITE A�DyD�RjESS N V� ���S'�p <br /> Q % (/ Street Number Direction Street Name Zi 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 /> piq ' /dD 13 his <br /> PHONE#2 Exr. BOS D7RICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESSFAX# <br /> Sofar AanC4 f ell• 37 73 <br /> CITY �p�C 7-G/r7 STATJr'�'Y ZIP 5� v ,(5 <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 HEAT.TH DEPARTMENT hourly charges associated with this project or <br /> 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, STATT4 an RAL s. <br /> APPLICANT'S SIGNATURE: DATE: /Z.,111 PROPERT4'I BUSINESS OWNER❑ OPERATOR I MANAGER OTHERAUTHORIZEDAGENT 1!' <br /> If APPLICANT is not theBILLiATG PR>r�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 JOAQUTN 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: �s��✓jfs J�`� ��j ��//�ti� <br /> COMMENTS: 63PAY 7viEy'4T 765 RECEWED <br /> DEC 0 1 2011 <br /> SAN JOAQVIN Co- . .Y <br /> HEALTH OEPART�N-NT <br /> ACCEPTED BY: III�C+ EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 54ylt- DATE: <br /> O <br /> Date Service Completed (if already completed): SERVICE CODE: 0.7, PIE: <br /> Fee Amount: Amount Paid �a• Payment Date lZ�t ('�S <br /> Payment Type Invoice# Check# Z� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11!1712003 <br />