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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SEE/RV/ICE REQUEST# <br /> OWNER OPERATOR <br /> CHECK I(BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS '2,'f <br /> / ,,,neer Direction vv Street Name CI 2i Cotl`e b <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i En. APN# LAND USE APPLICATION# <br /> (?, / I ft/ - &7 7 06 2Boll <br /> PHONE#2 Ea , BOS DISTRICTCT LOCATION CODE <br /> ( ) <br /> el l` <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS '] <br /> BUSINESS NAME PHONE# ET <br /> HOME or MAILING ADDRESS FAX# <br /> -b �/ U I I <br /> CITY - /ter STATE /'4 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 HEAL'T'H 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,S E nd FED w <br /> APPLICANT'S S ATU - ,D-ATE: 3./15 /T <br /> PROPERTY/BUSRNESS OWNER❑ OPERATOR/ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B/LLLNG PARTP 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 environmentaUsite 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: 5 L PAYMENT <br /> COMMENTS: E I VELD <br /> 3/aI/tom 0 q/i� MAR 0 5 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> <Ge9'1t/J HEALTH DEPARTMENT <br /> ACCEPTED BY: G-(r NV' EMPLOYEE#: DATE• �l S 1 <br /> ASSIGNED TO: Lf7 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: < PIE: L'3 <br /> Fee Amount: L V Amount Paid �G Payment Date 5 <br /> Payment Type ,% Invoice# Check# 12 Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />