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SAN JOA4OUNTY ENVIRONMENTAL HEALTOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />CITY STATE zip <br />oW G,rc>Ll i <br />-A o ©v ca l )L- <br />R 3 -3 C> <br />OWNER /OPERATOR <br />� ^ � �. � <br />f -j <br />OCT 2 9 2013 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS >_ <br />r <br />C� 2, -2,t, <br />Street mber <br />Direction <br />Street Name <br />EMPLOYEE #: <br />C ity <br />Zin Code <br />HOME or MAILING ADDRESS(if DifferentfromSite Address) <br />7(j yA a <br />EMPLOYEE #: <br />Q �S t --P-`-� � <br />Street Number <br />Date Service Completed (if already completed): O -`3 I (' l <br />J <br />Street Name <br />CITY (1 C? <br />�/` <br />Fee Amount: <br />STATE ZIP <br />VI r <br />PHONE#1 EXT. <br />APN # <br />z <br />b 3 003 <br />LAND USE APPLICATION # <br />(�D > 2 3 2S <br />Payment Type <br />Invoice # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( )�'1CfD`it( <br />lei <br />c.Ic <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BELLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />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. l I <br />APPLICANT'S SIGNATURE: DATE: <br />DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BtLLINGPARTZ 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: <br />N �(��fj7 <br />PAYMENT <br />COMMENTS: <br />CA'P :yL <br />G <br />oW G,rc>Ll i <br />e, <br />RECEIVED <br />OCT 2 9 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH nFL..RT.­L <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: Y 4 <br />ASSIGNED TO: <br />7(j yA a <br />EMPLOYEE #: <br />f <br />DATE: �O -0—Q t <br />Date Service Completed (if already completed): O -`3 I (' l <br />J <br />SERVICEC�OdDE: � <br />PIE: �t- <br />Fee Amount: <br />1 <br />Amount P i <br />Payment Date ;zq h 3 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />