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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# GG,��SERVICE tREQUEST# <br /> OWNER/OPERATOR *^ ^A -A 11 <br /> {_ �""v U EL— CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2-')60,7— V/I"5-(L nI OEf�l aj 5 7-36, <br /> Street Number Direction Street Name citv Zip 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 /> ( 7-01) 610- (07 27 l4 - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M` <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> DIU-cam] M\Jre-F'"'r zc�q 3 <br /> HOME or MAILING ADDRESS FAX# <br /> P.o . Box 2�16o (Zo9 ) 33 -177 Z3 <br /> CITY L vo I' STATE Ca ZIP C?S Z.¢/ <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 and FED ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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: <br /> COMMENTS: R C/� <br /> i E EIVED <br /> aZ7 Y2 "l�Jt t ted <br /> Cr <br /> JUN 2 7 2014 <br /> 30/m Ivt JOAQUIN IP >� E 7"IC SAN COUN <br /> ZailhJ) <br /> HE ENVIROME01TAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: yam_ P 1 E: <br /> Fee Amount: Amount Paid Payment Date an (t4 <br /> Payment Type I t Invoice# Check# �I�(OS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />