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SAN JOAQUOOUNTY ENVIRONMENTAL HEALT 'APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (%Vm V, e(d 5� r-A-Opp 1 -2,79 SR-6b 6 3 2:2 <br /> OWNER/OPERATOR <br /> CAnvr�n �^` CHECK If BILLING ADDRESS <br /> � <br /> FACILITY NAME �qj P✓�(I rJ`/ <br /> SITE ADDRESS �/✓� �tiK � / V. <br /> 75 Street Number Direction Street Name Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) a 1q <br /> PHONE#2 ExT. BOS DISTR CT FOC <br /> (NmCODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> b�C � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO E# ExT. <br /> ne ,/ 96 0 <br /> HOME or MAILING ADDRESS , FAU <br /> CITY -<dGr(f 1"eA / STATE ZIP e <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER ❑ OTHER AUTHORIZED AGENT -� <br /> If APPLICANT is not the BI NG 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: <br /> COMMENTS: <br /> RECEIVED <br /> OCT 17 2013 <br /> SAN <br /> OAO IN cOALNTY <br /> ACCEPTED BY: ��-v EMPLOYEE#: V9 T DATE: <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: rig PIE: 2-7? <br /> Fee Amount: �� Amount Paid Payment Date 171) <br /> Payment Type ✓ Invoice# Check# Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />