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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> vI G40olrl<ZclO <br /> OWNER/OPERATOR <br /> � _ CHECK If BILLING ADDRESS <br /> D /I 1' ot <br /> FACILITY NAME <br /> SITEr /ADDRES'S GIC i t/l te`� �j 1/e, � !L1� Gr1l I5337 <br /> `0 10 Street Number I Direction Street Name C!ty Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION DE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /�� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# iv r <br /> HOME or MAILING ADDRESS FAX# �® <br /> ( ) Pd O18 <br /> CITY STATE ZIP SAN J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizd"g�ONlpt�pUNn' <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With trti At <br /> activity will be billed to me or my business as identified on this form. ANT <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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 l 1 (g <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tille <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 /> t0 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: & �� <br /> r <br /> e �. <br /> PG '.SC ►1P C t- 1 kQ, 04 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: <br /> Fee Amount: �Z Amount Pa /S2 bD Payment Date �� r <br /> Payment Type s� Invoice# Check /* Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />