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6AN JOAQUIN (.OUNl'Y ENVIRONMENTAL tILALIH 11LPAKIMEN 1' <br /> S-y-DA710E REQUEST <br /> Type Business or Property FACILITY ID# ; SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> 1 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> -Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE# EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOK-1 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS r C ( <br /> J _3`J <br /> 2c)CITY \ STATE � i 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 /> I also certify that-I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN <br /> COUNTY Ordinance Codes,Sta rds,STATE and FEDERAL laws• ! I <br /> APPLICANT'S SIGNAT /laws <br /> DATE: 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR�MANAGER ❑ O ER AUTHORIZED AGENT❑ C� <br /> If APPLICANT is not the BILLING PARTY,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 <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: \ - PAYMENT <br /> COMMENTS: <br /> MAR 3 0 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: (j DATE:✓ 3 G f <br /> Date Service Completed (if already completed): SERVICE CODE: �' P I E:, O,P <br /> Fee Amount: Amount Paid 111�3 -0 Payment Date 3`3 D l <br /> Payment Type Invoice# Check# 4, T Received By: q <br /> EHD 48-02-025R FOR_M(Golden'Rod)' <br /> REVISED 11/17/2003 <br />