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SAN JOAQUIN (:OUNTY ENVIRONMENTAL HEALTH DErARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST,# <br /> > -7� N <br /> OWNER/OPERATOR / // t�iiECK If BILLING ADDRESS❑ <br /> G2J Ira w ^o c �, L4 (/r,NGa <br /> FACILITY NAME <br /> 40�' G G3 <br /> SITE ADDRESS 6;., <br /> /� SJ/� �j���j <br /> C •R Street Number D r(action ` `-'Z e'er eet Name Zi Code <br /> HOME Or MAILING ADDRESS (If Different froT Site Address) _ <br /> Fo �N <br /> � Street Number Street Name <br /> CITY Sr ZIP <br /> saw S6�a <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> (%'lam) Gt /1�C�� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> r REQUESTOR / CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# EXT. <br /> 9 G q 8 / <br /> HOME or MAILING ADDRESS �p FAX# <br /> t 2�././7 O /G?✓ r/^cI LR]ci /�G- c�G ( ) <br /> CITY �, o"�GV4 $TATF�ii ZIP Q> <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT S�jc �< <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 asse sment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It ed to me or <br /> my representative. R M <br /> TYPE OF SERVICE REQUESTED: l I (GI 114A, <br /> 61 <br /> COMMENTS: 0q4U� <br /> L CT yoo gRT A�Nry <br /> ACCEPTED BY:< EMPLOYEE#: DATE: n <br /> ASSIGNED TO: _ EMPLOYEE#: DATE: _ /( <br /> Date Service Completed (ii already completed): SERVICE CODE: P I E: 3 <br /> Fee Amount: ' 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 />