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SAN JOACS, COUNTY ENVIRONMENTAL HEAL*EPARTMENT U <br />SERVICE REQUEST <br />Type of Business or Property <br />G Com- w""j' <br />- <br />/y�FACILITY ID # <br />dW ��- 0 <br />SERVICE REQUEST # <br />Ua 10810 (02 <br />W ER / OPEfIlATOR <br />0 1 � <br />CITY STATE zip <br />CHECK if BILLING ADDRE <br />ACIUTyI <br />DEC 13 2013 <br />SIT ADDRESS <br />Street Number <br />Direction <br />% S `a/ �sMee1'I�ai�+e <br />V W A— <br />HOME or MAILING ADDRESS (If Different from Site A dress) <br />Street Number <br />HEALTH DEPARTMENT <br />Street Name <br />CITY <br />EMPLOYEE M 2_G 2_0 <br />STATE zip <br />PHONE A ExT• <br />( ) <br />�� <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST <br />[i f 'e�,,,- CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME <br />PHONE # EXT. <br />c�rJ-�7 5 <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 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. <br />APPLICANT'S SIGNATURE: z►- DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGE OTHER AUTHORIZED AGENT ❑ <br />/f APPLICANT 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i5 provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />-e-7— rrev F1 T- <br />PAYMENT <br />COMMENTS: <br />RECEIVED <br />DEC 13 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M 2_G 2_0 <br />DATE: <br />ASSIGNED TO: <br />�� <br />EMPLOYEE M 14 %2, <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ' /.] 9 <br />P / E: IL3 <br />Fee Amount:�� <br />' <br />Amount Paid <br />— , <br />PaymenttlDate a <br />Payment Type V <br />Invoice # <br />Check # <br />Received <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />