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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop _Property FACILITY ID# SERVICE REQUEST# <br /> -1-GCo JV'0LD�J1I �� s� qj <br /> OWNER/OP RATOR <br /> U CHECK If BILLING ADDRESS <br /> FACILITY NAME i <br /> 7�,7 WO z C <br /> SITE ADDRESS r <br /> Street Number I Direction A711 /D� Street Name � � Zi Code <br /> HOME Or M ]LING ADDRESS (If II/{verrent from Site Address) I <br /> (ice 1 / U Street Number Street Name 1 G <br /> CITYG'1 I <br /> Y-) EXT. <br /> C n ZIP <-1 �� C, <br /> PHONE#1 T` �O EXT• APN# LAND USE APPLIICCATION# <br /> PHONE ill EXT. BIDS DISTRICT LOCATION CODE <br /> (26 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# _ EXT. <br /> oL4 �a� 'Z' cq ZZ- 3 56 <br /> HOJE or MAILING ADDRESS FAX# <br /> CITY (b�K J 0 STATE ZIP -z-6-�' / <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/BUSINESS OWNER NNMMN 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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: r I q <br /> COMMENTS: T, C�� <br /> sq yJ <br /> ti�FryRo M �,9 <br /> O (! <br /> ACCEPTED BY: I �+ �� <br /> 4 EMPLOYEE#: (�� / ') DATE: 1 / 4,-,q <br /> ASSIGNED TO: l..CU EMPLOYEE#: V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: �CoU r <br /> Fee Amount:It Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />