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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> w�H 0C1 g <br /> NERI RATOR \ /J <br /> S- Y\\ C TO <br /> FACILITY NAME L @K { CHECK If BILLING A0DRE55 <br /> lJ I �y�/ I!� V ITy—n / <br /> S TE ADDRESS <br /> ` ,(LfL/1tr i <br /> greet 2J ber Direction ✓� ' �SNfe N (ZJI Code <br /> Or MAILING ADpRE58 If Different f 0m,,Site A d s) <br /> �nUl Street Number Street Name <br /> Cl l TE <br /> 1 \ (U <br /> PH WE#t Em APN# LAND USE APPLICATION# <br /> V) OV <br /> PHONE#2 Ex. BOB DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST <br /> `A ` CHECK If BILLING ADDRESS <br /> BUSINESS AME " vim+ V w P # E <br /> HOME INGADDRESS _ FAx# <br /> CITY STATqJ17V <br /> 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 jha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TA E and E Ll <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/M N GER ❑ OTHER AUTHORIZED AGENT <br /> IrAPPL/CANT is not fire BtLL/NG PART Prda torization 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. PAY <br /> TYPE OF SERVICE REQUESTED: QYl( {1S C �� ItEce1win <br /> COMMENTS: I`^� AUG 19 2011 <br /> SAI�11ORONA4 COUNT-, <br /> EALTH DTAL <br /> EPARTMENT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid �S a O Payment Date X//V2 <br /> t <br /> Payment Type Invoice# Check# 903S5 Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P�.o511�11.18 J <br />