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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gam � 'I—�?1C�1 S�"vo!&12s -2 <br /> OWNER/OPERATOR <br /> DC i CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> P0e <br /> SITE ADDRESS /V o(-G 3 v St- f 0C,1z-k--0✓) GjS'Z�Z <br /> Street Number Direction Street Name citv ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Gc ✓� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT __7LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ' � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# / EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> C7 P ( ) <br /> CITY O STATE LA ZIP q <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 /> I� 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:J �7� /� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 itessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the <br /> provided to me or my representative. IT ft T <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: Z� <br /> 'ORO tN Co <br /> QCT D�pMR TAJ <br /> N <br /> ACCEPTED BY: EMPLOYEE#: DATE: 0-lo. <br /> ASSIGNED TO: EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: 00 PIE: (uo2 <br /> Fee Amount: ��� Amount Paid rr, Payment Date � ,'j <br /> Payment Type 7 invoice# Check# q' Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />