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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4603,6 E�, cq 9&2 I <br /> OWNER/OPERATOR ` <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME h <br /> I NL. <br /> LkSITE ADDRESS •��� � )) <br /> Street Number Direction Street Name Cit Zi ode V <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#j ^ ?,-7 I r`, E,, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BIL�SILLING ADDRESS <br /> BUSINESS NAME ] ` �1 n (, p1�M/�1 n PHONE# �^\ EXT. <br /> , I <br /> HOME or MAILING ADDRESS C FAX# — <br /> ��) 37 ZS�-r� <br /> CITY r r STATE ZIP f^ " <br /> J 1 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FNDFRAL laws. q <br /> APPLICANT'S SIGNATURE: zliX <br /> ice, DATE: I ^ (j — It <br /> PROPER-IN /Bt siNESS OH NER❑ OPERATOR/MANAGER LJ OTHER AUTHORIZED AGENT❑ <br /> //APPLIc'IA7 is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 ENVIRONMI'.NTAL HFALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. WMENT <br /> TYPE OF SERVICE REQUESTED: LA- rz Z - <br /> COMMENTS: DEC 1 4 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: y <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( , PIE: <br /> i3 d <br /> Fee Amount: S. " Amount Paid '�� '— — Payment Date t 1!)L <br /> Payment Type Invoice# Check# Gr Receive By: <br /> s <br /> EHD 48-02-025 SR FORM(Golden Rod)V <br /> REVISED 11/17/2003 <br /> V <br />