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SAN JOAQU... vOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - I, <br /> OWNER I OPERATOR M �r <br /> /+ /0 A) � Lj � HECK if BILLING ADDRESS <br /> FACILITY NAME 1 <br /> SITE ADDRESS j <br /> Street Number Direction Street Name cityZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• N# LAND USE APPLICATION <br /> AP # <br /> ( ) l 3, : r,0 1 <br /> J <br /> PHONE#2 ExT. SOS DISTRICTL LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEtj n PHONE# EXT' <br /> HOME O�MAILING ADDRESS FAX# <br /> r 1�� c �c ES3_y / ( ) <br /> CITY / ��� 2 ( ^ 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 HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURES-�/ (1�' CJ <br /> DATE: <br /> PROPERTY I BUSINESS OWNER❑ PERAT ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization t0 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/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> n <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: v{(�'� i ! GLI — RAYIgENT <br /> RECEIVED <br /> � OCT 29 2014 <br /> ENVIHEALTH <br /> —N EA?A <br /> ACCEPTED BY: elf 4"Pw EMPLOYEE#: DATE: ( <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: Z 3�-, <br /> Fee Amount: �� v ` Amount Paid 3 laz) 0Payment Date <br /> [ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />