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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE BEQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN /OPE TOR <br /> CHECK ifBILLiNGADDRESS® <br /> FACILITY NAME 13 <br /> a✓t �� <br /> SITE ADDRESS e-q-�/15, vi <br /> Street Number I Direction Fla Street Name cgy BeCode l <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( i <br /> CONTRACTOR SERVICE REQ VESTOR <br /> REQUESTOR y CHECK if BILLING ADDRESS <br /> W' <br /> LA <br /> BUSINESS NAMEAb i i n 4 � ^ � P NONE $ �/ R,� r� Ext. <br /> HOME or MAILING ADDRESS Q 6i zl.C:C FAx#lJ l(Jy 0 <br /> t-L'UZU'(R I ) <br /> CITY Q _ !�,5� CEL <br /> 4 STATE n ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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, STATE and FEDERAL laws. rte{r <br /> APPLICANT'S SIGNATURE: s .Gt_J�(.L� DATE: I`Ug <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT tat(I ILc4 <br /> if APPLICANT is not the BILLING PARTY.proof of authorization to sign is required VTitle <br /> AUTHORIZATION TO RELEASE INFOR TION: When applicable, 1, 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE! <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />