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SAN JOAQI OUNTY ENVIRONMENTAL HEALT&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> / CHECK if BILLING ADDRESS <br /> FACILITY NAME / <br /> Aai <br /> SITE ADDRESS TI-Irl� <br /> Street Number Direction Street Name •�{ i 2iGC�ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) /� � <br /> Street Number A Street Name`(, <br /> CITY SIATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> /� ( ) 'IL191Y <br /> CITY STA ZIP n <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 anddFFEDDEERAL laws. / <br /> APPLICANT'S SIGNATURE: . � DATE:f <br /> PROPERTY/BUSINESS OWNER❑ �r OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a �6yr- oi�ru azao, <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: CAST / —j— / j PAYMENI <br /> COMMENTS: RECEIVED <br /> APR 2 0 2012 <br /> SAN JOAQUIN COUN-ry <br /> ENVIRONMENTAL <br /> HEALTH DEPARTLENT <br /> ACCEPTED BY: � EMPLOYEE#: DATE: 12— <br /> ASSIGNED <br /> ZASSIGNED TO: EMPLOYEE#: DATE: Lt 2—, t-2— <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: C PIE: �c,q <br /> Fee Amount: ✓'T: G/ 5 Amount Paid IF3� 0 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (� j <br />