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SAN JOAQUIROUNTY ENVIRONMENTAL HEALTHIPEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ty wee r- L G 1,-5 pL <br /> OWNER I OPERATOR Cue <br /> r� / I vie— <br /> � CHECK if BILLING ADDRESS 13FACILITY NAME V ` <br /> SITE ADDRESS2—,. <br /> Street Numbet st N" city ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) ' <br /> (/ Street Number pot t r I 1ft NamVe` <br /> CITY � � �� STAT ZIP <br /> PHONE#1 ExT l APN# LAND USE APPLICATION <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTORrI n <br /> V ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> �I�k� Cts Cuvt�� l <br /> HOME or MAILING ADDRESS FAX# <br /> CITY -(,k 1 n STATE C ZIP AL <br /> BILLING ACKNOWL DGEMENT: 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,STTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT1e <br /> IfAPPLICAArT is not the BILLIIVG 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: S r'(/ j� +h✓c�Q�r �`��*ri <br /> COMMENTS: PAYMENT <br /> 6/mss//y- 0��' 0".' ,� ��., 7� <br /> � RECEIVED <br /> JUN 19 2014 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: /L!��;P P 176,�/i`�` EMPLOYEE#: iltflf'o p11; P <br /> ASSIGNED TO: p 4,4,, ,-f, EMPLOYEE M yd J?i0 DATE: 'd/1-711y <br /> Date Service Completed (if already completed): 6 a S l y SERVICE CODE: 3 DO P I E: 4-'/0 .7 <br /> Fee Amount: -3 Amount Paid. — Payment Date <br /> Payment Type Invoice# Check#J 7Z I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />