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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property j�FACILITY ID# (SERVICE <br /> 'IREQUEST# i <br /> t �S G�,LCax1� I <br /> proV g�F <br /> OWNER!OPERATOR CHECK If BILLING ADDRESS r <br /> FACILETYNAME_ CA,a; 's <br /> SITE ADDRESS a51� <br /> Street Number Direction - — Street Name _ Zip Code _ <br /> ` HOME or UlA.luw-,ADDRESS (tf Different from Site Address) <br /> Street Number � - Street Name <br /> CITY STATE Zip <br /> PHONE#1Ext. APN# .AND USE APPLICATION# <br /> I (U.t)Z1�4�r¢6 <br /> 71 - <br /> PHONE 412 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br />• CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO E# ExT. <br /> Geo ChJ. `s g1 <br /> HOME or MAILING ADDRESS I f �P+nw-f a'T &i U, FAX# <br /> 4 1 <br /> CITY STATE �. ZIP _.ct7 <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 /> APPLICA'NT'S SIGfaATURE: �. DATE: <br /> PROPER-,Y I BUSINESS OWNER� OPERATOR/ ANAGER ❑ OTMER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 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 to me Or <br /> my representative. <br /> I TYPE OF SERvicE REQUESTED: <br /> 0 u d rtmwwo nr�lvrrl�It�l1C� <br /> COMMENTS: JUN 0 2 7` 16 <br /> SAN j0AUbIN C JUNTY <br /> ENVIROMEN AL <br /> IJEAUTH DEPAR MENT <br /> ACCEPTED BY: a an EMPLOYEE t'E: DATE: 0 <br /> i ASSIGNED TO: S s11t S m EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed):, f ' SERVICE CODE: Sic, <br /> 0 Le <br /> I PIE: 1 <br /> Fee Amount: Amount Paid '"3 0 . 00 Payment Date 06, 0:2 A6 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />