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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 Ek on :T3-5-T- <br /> OWNER I OPERATOR T� IIM� <br /> O CHECK If BILLING ADDRESS= <br /> FACILITY NAME / `J <br /> c , EI a e M lcc,n rwd <br /> / <br /> SITE ADDRESS 3 0(o Y0SC' fr1 , }-a CN4-f— }� ` L - (-)3�ib <br /> Street Number Direction Street Name city 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 /> (Gib) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME )` (, GGd PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 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: DATE: <br /> PROPERTY I BUSINESS OWNER P OPERATOR I MANAGER 6THER 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, 1, 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 asses ent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time rovided to me or <br /> my representative. /� P <br /> TYPE OF SERVICE REQUESTED: , 6 .(t_ `'ii G <br /> COMMENTS: U .�( <br /> �C> <br /> ACCEPTED BY: ow-d4Li 4 1 � EMPLOYEE M � �D� DATE: 't /_ � -7 <br /> ASSIGNED TO: 6EMPLOYEE G/ DATE: <br /> 11 CS�� 1 <br /> Date Service Completed (if already completed): 777FSERVICE CODE: _t P/E: <br /> Fee Amount: _ j 5 2 ©a Amount Paid .` I L� , r Payment Date <br /> Payment Type> , Invoice# Check# j(���' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />