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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST u <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR '- rn <br /> U IAC-,Yhfv 2— W JJ 1,.7 CHECK If BILLING AODRES <br /> Ja <br /> FACILITY NAME !1 1�1 G-GD 0V (i'l M 4- <br /> 741 <br /> SITE AQDDRESSr�'11F,— lS1 P` <br /> (4 I , Str Number Oirectlon Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site A e s) Cl_ <br /> Street Number Street Name <br /> CITY STATE ZIP /z g <br /> PHONE#TAPN# LAND USE APPLICATION# (( <br /> 1-9 j) �-�1 -25-7 <br /> PHONE#2 ET. BOIS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSff <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 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 F ERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNERzr OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If I <br /> If APPLICANT IS not the BILLING PARTY.proof of authorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me or <br /> my representative. T <br /> TYPE OF SERVICE REQUESTED: US'! e. . t <br /> COMMENTS: - SE6tlIVED <br /> -1 <br /> JUL 2 2014 <br /> SA ENS <br /> VIIROMfN AL <br /> pFtTMENT <br /> ACCEPTED BY:S,r�26��/J tg EMPLOYEE#: DATE: <br /> ASSIGNED TO: � � -�-%>rp -/j�/I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): D SERVICE CODE: .e PIE:t:-�2�� <br /> Fee Amount: `� Z Amount Paid Payment Date a•` <br /> Payment Type Invoice# Check# r Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />