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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 /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �QC� ,�� �Y2 7 9s: <br /> Street Number Direction Street Name City de <br /> HOME or MAILING ADDRESS (IfDTprent from Site Address) <br /> 2-72- 4 S E,44z),-2-6 4� Street Number Street Name <br /> CITY 57._7C _/moi 1 STATE�. zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> a,P� ) 4 9'/- 3sL{2- <br /> PH E#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R�QUESTOR CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME / /� �� u U PH L# g —3 S y ZEXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 5 l� STATE ZIP <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 HEALTI-i 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 an at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandaJATE and F L laws. <br /> APPLICANT'S SIGNATURE: DATE: 1/ Z l/ <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPL/CANT is not the L G PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IN RMATION: When applicable, 1,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. / l <br /> TYPE OF SERVICE REQUESTED: �—D U/� C-O/ ��—�fF r/�'J <br /> COMMENTS: <br /> �'.CEIVED <br /> NOV 2 2 2011 <br /> ,AN JOAQUIN cooNTY <br /> ENVIRONMENTAL <br /> ­IEALFH DEPARTMENT <br /> ACCEPTED BY: (_e E-- EMPLOYEE#: Qrr DATE: <br /> ASSIGNED TO: EMPLOYEE#: U/ q e� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ' U Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />