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SAN JOAQL .N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b i�v) SROO7y� d�! <br /> OW ER I OPERATOR <br /> U� I ��� ! Q 0-1 CHECK If BILLING ADDRESS� <br /> FACILITY NAME r p A4 <br /> r G/� TIC C . 000 <br /> SITE ADDRESS Q'C •}� G q -S G <br /> Street Number Direction treet Name / <br /> Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> P( ONE#1 EXT. APN# LAND USE APPLICATION# <br /> �%) L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ �1 <br /> I /0-r�/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME / [ PHONE# XT. <br /> G r-Cit 6 G C' C� Ocl 4-12 7 ,5 <br /> I E or�11�G ADD ES + G r <br /> FAX# ) <br /> CITY 0 C <br /> 1{ STATE ZIP 2 <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: ��U Q'�R a' (e:�rk��'J ,qc DATE: O 3 <br /> 1 117 <br /> PROPERTY/BUSINESS OWNER❑ 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: food V ((* Mec h U n <br /> COMMENTS: <br /> ACCEPTED BY: �� 'VI�L{ n 6, EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1EMPLOYEE M DATE: <br /> Date Service Complet d (if already c mpleted): SERVICE CODE: PIE: b 7J <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 />