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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 14 SERVICE REQUEST <br /> OWNER/OPERATO` <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME G CJ I <br /> SITE ADDRESS //l[I C I t 1 <br /> Street Number Direction �r(Aa rame Gtv 2io Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name _ <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND UsE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CO CTOR/ SERVICE REQUESTQR <br /> REQUESTORn l n CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> eioit <br /> (� C <br /> HOME or MAILING ADDRESS _ FAX# <br /> ( ) <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 thi <br /> also certify that I have prepared aST <br /> ation and th t th w rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stan anFED law . <br /> APPLICANT'S SIGNATURE: , DATE: z <br /> � 120/ <br /> PROPERTY I BUSINESS OWNER 10OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT Is not the BILLING PARTY,proof ofauthorization f0 Sign is required Title <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. e <br /> TYPE OF SERVICE REQUESTED: P'(() Ckc 'k 442 REQ� <br /> COMMENTS: Nei .7 <br /> kxSAN JOAQui,-4 COUNlY J � �I��lENVII10MENTAL <br /> HEALTH DF-PARTMEN <br /> ACCEPTED BY: /-1�7 EMPLOYEE#: DATE: 15 <br /> ASSIGNED TO: r�// I EM PLO(EE#: DATE: L /I <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid S�j S f�CJ Paymen Date <br /> Payment Type Invoice# Check# S PAyqTM7Fd By: <br /> RE <br /> EHD 48-02-025 AUG 0 5 ZOt�FORM(Golden Rod) <br /> 07/17/08 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEAILTH©EPARTMENT <br />