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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '3� U6 1 SP"'_uv �_'�' <br /> OWNER/OPERATOR' , ���r CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME (? • / 7(' <br /> SITE ADORES /S + _�1 <br /> {� (^J-'�treet N be Direction S Nari18 `� C� i Cade <br /> HOME or ILING ADDRESS (If Different from Site Address) <br /> j -- Ar" <br /> j', Street Number Street Name <br /> STATE ZIP <br /> CITY � 67 _ <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> BUSINESS NAME PHONE# ExT' <br /> C <br /> HOME or MAILING ADDRESS FAX# <br /> ;7 J S <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,SYAYE and FEDERAL) S. t <br /> . / <br /> APPLICANT'S SIGNATURE: DATE: <br /> /�,f <br /> PROPERTY/BUSINESS OWNER OPERATOR/tV1ANAGER 13OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> aaddress, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> in to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> pr to me or my representative. <br /> T ICE REQUESTED: !ef E) PAYMENT <br /> C TS: . <br /> �= JUL -1 2011 <br /> w; <br /> SAN.ioAQirN COUNTY <br /> ENVIRONMENTAL <br /> spa HEALTH DEPARTMENT <br /> r <br /> ACC Y: EMPLOYEE#: e_'-131y DATE:. <br /> ASSIGNED TO: V-12 (eft EMPLOYEE#: - f-3 DATE: /f <br /> Date Service Completed (if already completed): SERVICE CODE: S" P 1 E: <br /> Fee Amount: , :?V I Amount Paid $ 1 Payment Date <br /> Payment Type LI Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />