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SAN JOAQUiN COUNTS'ENVIRONMENTAL REALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'S:'q612 - ::L -SR0 b 6-7:P-& 2- <br /> OWNER/OPERATOR <br /> CHECK if BILLING,ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS yn� <br /> Street Num er <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t Name� <br /> CiTYLr D-y.� I <br /> ATEzip <br /> PHONE#1 ll EXT• API# LAND USE APPLICATION# <br /> (2Ut► Z(P3 -.s33b 1 0c (5�' <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR nn <br /> REQUESTOR CHECKIf BILLING ADDRESSO <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT': I, the undersigned property or business owner, operator or anthorized agent of same, <br /> acknowledge that all site and/or project specific ENvIR0N1NiiNT.At.HEAi,m DEPARTMENT hourly charges associated with this prci)ect <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certifv that I have prepared this application and that the work to be performed will be done in accordance with all SAN 3OAQII N <br /> COLfNTY Ordinance Codes,Sttmdards,STATE aiUl FEL)m 1: T <br /> APPLICANT'SSIGNATU�RyE: � _�_ DATE: <br /> PROPERTY/BUSINESS OWNERIp OPERA-rUR/MANAGER L OTItF:R AUTHORIZED AGLNT <br /> If'APPLICANT is not du-B1L1JN(-,P.,I TY.proof of authorization to sign is regaired Titre <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, geolechnicat data and/or environmental/site assessment <br /> infortmation to the CAN JO.AQUIN COUNTY ENvIR0N'*kMNTAL I-IEALTFI DEPARTMENT as soon as it is available /� �c a it is <br /> provided to n1e or my representative. " " G <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MAY 3 0 Z013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: / �Bti't EMPLOYEE#: 3173' DATE: N!5-ZTQ- <br /> ASSIGNED.TA: EMPLOYEE#: � DATE: J�X/-13 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Pa'I��6, �� Payment Date <br /> Payment Type Invoice# Check# c Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />