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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ,FACILITY <br /> ID# SERVICES REQUEST# <br /> r, �� <br /> OWNER/OPERATOR � <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE AD`rUBESS <br /> 7r Street Number Direction Atra(t _ C � G Sp C <br /> HOM IN?DDDD-�RESS If Different from Site AdOress7/,9-1 <br /> / P <br /> G V C /,9 N Street Number Street Name <br /> CITY U � G STATEZIP <br /> PHONE#� q9 1 ���EXT. ,qPN# LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> I ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS <br /> cur <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS� FAX#/ems <br /> CITY U STATE ` V zip(75 <br /> U <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 identi' this form. <br /> I also certify that I have prepared this a i Ion and at the o to be performed will be done in accordance with all S JOAQUIN <br /> COUNTY Ordinance Codes, Standard , TA and F ERAL law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OP R ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPucANris not the ILLI PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMAT'ON: 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/sitermation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same ti "' me or <br /> my representative. f�'�7 GG ,�/ <br /> TYPE OF SERVICE REQUESTED: I i�, r'h U in AUG 2 9 <br /> COMMENTS: SAN NV JOAQUIN Co <br /> Mry <br /> HEALT OMENFi DTAL <br /> EPARTMENT <br /> ACCEPTED BY: 6flEMPLOYEE#: DATE: 1 2G� <br /> ASSIGNED TO: r� �I Jt / j< EMPLOYEE#: DATE: 12- fj j( <br /> Date Service C mt leted (if already completed): 1 SERVICE CODE: SC U O�j PIE: <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 />