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SAN JOAQ a COUNTY ENVIRONMENTAL HEALWEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> avicz-1Y12o <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> n� E\�0 > I 4F 0\n a F/7- <br /> FACILITY NAME s \^ p�—`^ <br /> A��A�M' ?,a\ <br /> SITE ADDRESS ) \���-t� �^� / 05707 5Z0 7 <br /> ba 9 Direction tr N <br /> Street Number <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number I StreetNam <br /> CITY STATE ZIP <br /> 0 21-0 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION COpE <br /> ( ) l/ <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: 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 F ERALla S. <br /> APPLICANT'S SIGNATURE ^ � <br /> DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER _. HORIZED 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 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: RECEIVED <br /> OCT 17 2012 <br /> SAN JOACUR4 COUNTY <br /> ENYI RON M.EHT4 <br /> HRUTH OpmrM ff <br /> _. ACCEPTED BY: EMPLOYEE-#: <br /> DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid r ; ;- Payment Date f ; <br /> �. <br /> Payment Type lj Invoice# Check# RbceivedBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />