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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 1JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (A cj,�) 2" 0 (�,3/3,-?, <br /> OWNER i O ERATOR <br /> n •1� CHECK if BILLING ADDRESS <br /> [Do <br /> FACILITY NAME <br /> 1 L <br /> SITE ADD SS440 <br /> Street Number I Direction I I Nrbr�ii Citi Zip Cody. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 /I�� ''') EXT. APN# LAND USE APPLICATION# <br /> -9 / <br /> PHq #2 EXT• BOS DISTRICT LOCATION CODE <br /> �� <br /> .'' 2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �; /�4 i � <br /> Q� CHECK If BILLING ADDRESS <br /> IV <br /> BUSINESS NAME I Ito <br /> PHONO EXT. <br /> HOME Or MAILING ADDRESS & n,t (L/y�f/AX#` � <br /> 9 - IIS L „_) �I# <br /> CITYO-fI STATE ZIP <br /> `^ <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,ST T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 C'111 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AG <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is requiir Tit le <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 t0 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: PAYMENT <br /> COMMENTS: <br /> JUL 2 8 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 <br /> L <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if al a y completed): SERVICE CODE: P I E: 21-309 <br /> "7, 01 <br /> 71 Fee Amount: Amount Paid p Payment Date n v (! <br /> Payment Type ✓ Invoice# Check# ecce`ivcd By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />