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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUL T# <br /> Gas svc�b O Y) ��/� o �� l! <br /> WNER/OPERATOR CHECK If BILLING ADDRESS D <br /> i <br /> FACILITY NAME <br /> SITE ADDRESS r)_)o r) lJ �e� ��� /1� 9S✓t0� <br /> Street Number I Direction Street Name Ci u7 Zio Code <br /> H E OrAILING ADDRESS (If Different from Site Address) <br /> S �. J6 v V C. Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1EXT APN# LAND USE APPLICATION# <br /> Q0 61,9 _5108 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> S r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 19 PHONE# EXT. <br /> 2 �I��J o <br /> HOME or MAILING ADDRES f� FAX# <br /> UC � y ( ) <br /> CITY J I uC STATE //L 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 /> I also certify that I have prepared this appl' on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATEE )��/ <br /> PROPERTY I BUSINESS OWNER-� OPERATOR/MANAGER El OTHER AUTHORIZED AGENT ❑ I/ ,co <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization to sigh 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 /> 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. <br /> TYPE OF SERVICE REQUESTED: �� d C <br /> COMMENTS: <br /> RECEIVED <br /> Ft,6 13 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: ATE: a ( '5,nr i <br /> ASSIGNED TO: D L�w 7r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ` p� <br /> Fee Amount: l p Amount Paid � Payment Date 2 l3 I� <br /> Payment Typ Invoice# Check# 1 (;�j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />