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OEM <br />SAN JOAQ*OUNTY ENVIRONMENTAL HEALTI&PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />fa IC- <br />BUSINESS NAME <br />FACILITY ID # <br />F4 ooeo 3 °1.13 <br />SERVICE REQUEST # <br />Se CO &52-39 <br />OWNER/ OPERATOR <br />q <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />p <br />� <br />HE_ALVIRONMENT <br />n-1 DEPARTMENT <br />SITE ADDRESS <br />Street Number <br />tai <br />Direction <br />Street Name <br />city <br />_ <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />P / E: 23 a P <br />STATE ZIP <br />PHONE #1 <br />ExT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 <br />( ) <br />Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESTUEAS <br />BUSINESS NAME <br />�� r <br />PHO E # r ` Exr' <br />HOME or MAILING ADDRESS <br />FAx # _ <br />CITY STATE ZIP 5 <br />l �J <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. <br />APPLICANT'S SIGNATURE: `l DATE <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ' <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required `` Title <br />AUTHORIZATION TO RELEASE INFORIl1ATION: 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 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 />U S i— /��F i / <br />COMMENTS: <br />RECEIVED <br />JUL - 2 2012 <br />SAN JOAQUIN COUNTY <br />HE_ALVIRONMENT <br />n-1 DEPARTMENT <br />ACCEPTED BY: Lid t ) e <br />EMPLOYEE #: q() 1� <br />DATE: 7 / Z <br />!� <br />ASSIGNED TO: �_cA P t r <br />EMPLOYEE #: 1 . Z2 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1? <br />P / E: 23 a P <br />Fee Amount: c `; <br />Amount Paid%3-) <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # l 77r' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />