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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C a'j fzz-ni t iFA u C)i 5k 01 I5115 <br /> OWNER/OPERATOR WYI 2 �'(ed CHECK If BILLING ADDRESS❑ <br /> nO Y/ <br /> FACILITY NAME G-MP � G 1^o p <br /> SITE ADDRESS N5� Q ►C1i) UkVA C,��O <br /> Street Number Directio I t Name cityCode <br /> HOME or MAILING ADDRESS (if Different from Site Address) �M o R� 'P '� <br /> Coq+ ��` h I i 6J) u Street Number Street Name <br /> CITY L— I „y.-.IGC C 1� STATE <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (q) )� 2r � <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> gZl W <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORr <br /> fCHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> Co LAIIL ( --�' ) <br /> CITY -il O L / STATE C 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 <br /> 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saylle time it is <br /> provided to me or my representative. 1 - f-AY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 01ct"C)c 0 t� v�s� P 1Z�v-&AL E� 31 201 <br /> N FORQV/ty C <br /> on� 7' <br /> ACCEPTED BY: n n v EMPLOYEE#: DATE: I 2t (/� <br /> ASSIGNED TO: 1 V Y EMPLOYEE#: DATE: 1 �J Z_ 1 `I A <br /> Date Service Completed (if already completed): SERVICE CODE: ���, 1 l P 1 E: <br /> Fee Amount: ��� Amount Paid ` ., Payment Date / � � 9 <br /> Payment Type Invoice# Check# = Received By. <br /> r. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />