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SAN JOAQIWOUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# IF SERVICE REQUEST# <br /> G IN s ST z 63 11 S/Qoa W>'Y d�3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ��� <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> (,)o5) S 3 - 82?3 <br /> PHONE#2 EXT. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EZT. <br /> HOME Or MAILING ADDRESS FAX# <br /> (o ( ) .?I - 6o I3 <br /> CITY G , D W— STATE (fi,�) ZIP ?i <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: W�� Lti ItJL DATE...:./ <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT tJ <br /> If APPLICANT is not the BILLING PARTY proof of authorization 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. <br /> TYPE OF SERVICE REQUESTED: — M <br /> ENT <br /> COMMENTS: NLUEIVED <br /> JAN 13 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DE <br /> ACCEPTED BY: EMPLOYEE MDATE: (011-0 <br /> ASSIGNED TO: EMPLOYEE If: JDATE:I <br /> Date Service Completed (If already completed): SERVICE CGDE: 8 P 1 E: aL <br /> Fee Amount: $ cm Amount Paid p� Payment Date �3 <br /> Payment Type L/ Invoice# Check# `1�6 D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />