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SAN JOAQV COUNTY ENVIRONMENTAL HEALODEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA ��t_7 ��--(� �"O x-00 1 <br /> 54 <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> AGILITY NAME Su. C-e <br /> SITE ADDRESS '' <br /> -``� olv' �� �l ti ��-� T (VI a w <br /> Street Number Direction Street Name Cit Zi Code <br /> ME Or MAILING ADDRESS (If Different from Site Address) / 2 �P �L/c�f✓ <br /> J Street Number Street Name <br /> -CITY �/ � �y STATE ��- Ze <br /> PHONE#1 EXT T PN# 3�01 l LAND USE APPLICATION# <br /> HONE#2 EXT. BOS DISTRICT LOCATION C DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <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 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. 1 /q+ c <br /> APPLICANT'S SIGNATU AE: --2T 12-111 �7 <br /> / t <br /> PROPERTY/BUSINESS OWNER OP OR/11'IANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. r <br /> TYPE OF SERVICE REQUESTED: (/�b�SVb !.V t—JXq <br /> COMMENTS: �/����L�Nv"'1/�- �,.. I���i/V"�� b 1/'�(� ✓�` <br /> �lfJ Sq-No 1 2014 <br /> HFgLTt QTp UN <br /> AHTMF <br /> ACCEPTED BY: �`�(f y^ i EMPLOYEE#: DATE: <br /> ASSIGNED TO: K ot, L-'-), EMPLOYEE#: DATE: T «t l <br /> Date Service Completed (if already completed): SERVICE CODE: p ( P/E: ) <br /> Fee Amount: l 2 S Amount Pal / - til) Payment Date <br /> Payment Type Invoice# Check# Received By:, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />