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SAN JOAQU, BOUNTY ENVIRONMENTAL HEALTH G__ ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a /�� qC) <br /> ;R NER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME t _ <br /> c v <br /> SITE <br /> "T Stre mber ADDRE� n•Lr�(� 1`2- <br /> �{`"�C �it�JZG6 <br /> �Gt uDire(ction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> • Street Number Street Name <br /> CITY / STATE ZIP <br /> GqS7-0 C4 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20-J '--1 Z©—151 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR\, <br /> x � CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# EXT. <br /> ac <br /> 0 <br /> HOME or MAILING ADDRESS 1 _ 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 /> 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, STATEand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ` DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATORJ 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, 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS M�iII��me or <br /> my representative. �• ��11►r,,pp rN <br /> TYPE OF SERVICE REQUESTED: f f ^ GQ <br /> COMMENTS: // 2015 <br /> SA E J0 A QUlty COU <br /> lvr <br /> H�q`T H De AF,AL T <br /> ACCEPTED BY: l EMPLOYEE#: DATE: <br /> ASSIGNED T /`/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type "ice Invoice# Check# Received By, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />