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I <br /> "els <br /> SAN JOAQUIS—OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &CL S s4aa;� -e 5 3 77 2�- 6rzoo o <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> kffcl� <br /> FACILITY NAME L7 I^ _ <br /> SITE ADDRESS .21 3-75w G ran b T---a C <br /> T'?5--3 7 <br /> (, <br /> Street Number Direction treet Name cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) re <br /> f/`1 L1 O i �.n S()Y\ 7-V 9 <br /> Street Number Street Name <br /> CITY a r)6 STATE /r n ZIP 9(78 G <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# l <br /> ( ) 311- q-?Q tag oZttf— o20.- I <br /> PHONE#2 EXT. BOS DISTRICT LOCATI.QN CODE <br /> 1 5- <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: 1, 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: DATE: <br /> PROPERTY/BUSINESS OWNER C 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 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 so as it is available and at the same time it is <br /> provided to me or my representative. GL S ( CO AJ S LLE <br /> TYPE OF SERVICE REQUESTED: TI61U PA`(meff <br /> COMMENTS: S CJS <br /> �J JUN 21 2010 <br /> SAH JOAQUIN COUNTY <br /> EWIROHMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Q(_i V me 'r EMPLOYEE#: 3 L i DATE: <br /> ASSIGNED TO: a VE�yt EMPLOYEE#: l �L� DATE: 2{ / 0 <br /> Date Service Completed (if already completed): SERVICE CODE: ©(Q PIE: <br /> ,Z3 <br /> Fee Amount:it �s VL) Amount Paid S (DD Payment Date 1i <br /> Payment Type Invoice# Check# /D3L� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />