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SAN JOAQUV '7UNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property n FACILITY ID# SERVICE REQUEST# <br /> -2- <br /> OWNER/ <br /> -OWNER/OPERATOR <br /> • C• CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS �O D I � 0rl417 <br /> Street Number Dlrectlon re 1N I ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> tSr)) SSa 0-- a <br /> PHONE#T EXT. BOS DISTRICT, LOCATION CODE <br /> ( ) 3 C(�O <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHXJ ?L1 EXT. <br /> HOME or MAILING ADDRESSO /a��-- FAX# <br /> Box 1/3- 0�) <br /> CITY 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 <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 app 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and FEDERAL laws. Q� /� <br /> APPLICANT'S SIGNATURE: 71 4t"M& :1DATE: C� //� /V <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT/Y,�4 <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to slgn 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 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. <br /> TYPE OF SERVICE REQUESTED: LI,S <br /> COMMENTS: <br /> AUS 17 2010 <br /> SA ENV RONME SENT <br /> HF�-TH DEPAR <br /> ACCEPTED BY: �Li v�/ EMPLOYEE#: trJ 7 I DATE: C-It 7 r <br /> ASSIGNED TO: 4 rXc=eS EMPLOYEE#: 4-(03 6 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E: 2 <br /> Fee Amount: 3 (06 CU Amount Paid 3 _ Payment Date <br /> Payment Type Invoice# Check# Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />