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SAN JOAQL —"OUNTY ENVIRONMENTAL HEALTI 31PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 ZS � b <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> a C llrkei A <br /> SITE ADDRESS (4 (a C 6-rniI,k;Y,,,e— '"C-, g5-5% <br /> Street Number Direction Street Name 'ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr_ APN# LAND USE APPLICATION# <br /> PHONE#2 E%T. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> r <br /> HOME or MAILING ADDRESS FAX# <br /> L*nxlj 1 rlo ) <br /> CITY _ STATE N ZIP 5 <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: Q'r------rj L �j� DATE: gyve_ (, .2.01.1- <br /> P ROPERTY I <br /> 2.01t.PROPERTY/BUSINESS OWNER E3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IIA <br /> lf,4PPL/C.ANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is <br /> provided to me or my representative. FWMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: JUN -C 2012 <br /> ' •1 L <br /> SAN JOAQUIN COUNT' <br /> EHV'RONME-Y"AI. <br /> f HEALTH IE=AP.r MF.NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already, completed): SERVICE CODE: �Z PIE: / <br /> Fee Amount: Amount Paid 412-svr Co Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />