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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 <br /> S• CHECK if BILLING ADDRESS❑ <br /> FAce.rrYN41E ��,•© <br /> n � <br /> SITEADDRESS Ss� �alQ1t� f <br /> Street Wumher Direction Street Name CIr Z11)Code <br /> HOME or MAILINGADDRESS (If Different from Site Address) ' <br /> Street N umber Street Name <br /> CITY STATE Zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BOS DISTRICT LOCATioN CODE <br /> CONTk-kiCTOR/SER1710E REQI.TESTOR <br /> R ECILIESTO R CHECK if BILLING ADDRESS❑ <br /> 1 <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> A c ) <br /> CITY STATE A ZIP <br /> BILLING ACKNOWLEDGEMErk I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project slaeclfic ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity Wa be billed to me or my business as Identified on this form. <br /> I also certify that I have prepared this appllcation and that the work to be performed will be done In accordance with all SAN JOAQUIN <br /> COUNTY oidi lance Codes,Standards, STATE and FEDERAL I S M, i <br /> s IV, <br /> u.-; <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY[BUSINESS OWNERY- OPERATOR/MANAGER D HERAUTHORIZEDAGENT i <br /> ffAPPUCANT is not the BILLING PAF2TY,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 above <br /> site address, hereby authorize the release of any and all results. geotechnical data and/or environmental/slte assessment Informatlon <br /> t0 the SAN JOAQU14 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anti at the sam time It Is provided to me or <br /> my represents <br /> p yY <br /> TYPE of t� 'T �D: (i/S% <br /> CorvrrtENTS: Or" 28 <br /> NUV 20132013 <br /> SAN JOAOUIN COUN <br /> E`14VIFIOMF <br /> HEAL17K DEPARTMEO <br /> ACCEPTED BY: " n tj EMPLOYEE# Z6 ( DATE: U-2,613 <br /> ASSIGNED TO: 0`'" 11 TTW- EMPLOYEE# ` - q V DATE: [ 1 <br /> Date Service Completed'(if already completed): SERVICE CODE: �;6� P I C i1'2 <br /> Fee Amount: Amount Paid -75-0.6,D Payment Date .26�3 (J d <br /> Payment Type ✓ Invoice# Check* 1536 Received By: <br /> EHD 48-02-025 l [� SR FORM(Golden Rod) <br />