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SAN JOAk,—,N COUNTY ENVIRONMENTAL HEALTH LrEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ONER/Oq <br /> �� PERATOR C;V_).Z CHECK If BILLING ADDRESS E] <br /> FACILITY NAME -tel V <br /> L IJ <br /> SITE ADDRESS <br /> Street Number Direction I Str t Name IN ZIp Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> C 1 Gt L L' 6"'` Street Number Street Name <br /> CITY STATE <br /> SIG C11,� GAS L� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (_ v Cj G��'1 'J L' •� CHECK If BILLING ADDRESS <br /> BUSINESS NAME C PHONE ExT. <br /> (VSs V'4 <br /> HOMEor MAILING ADDRESS FAX# <br /> CITY siL 6�;ftv\ STATEZIP C) SL <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,STAT:? <br /> n DERAL laws. <br /> APPLICANT'S SIGNATURE: ? DATE: l <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title M__.".A <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located of-"a6o> <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infty ��` a` <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prooly me 011!70 <br /> my representative. 3� <br /> TYPE OF SERVICE REQUESTED: 7-:;c1 C C-K-- 14-�OqQ <br /> COMMENTS: �T{y ✓M O(7 <br /> TME <br /> ACCEPTED BY: (-N EMPLOYEE#: DATE:C_ <br /> ASSIGNED T0: r_ EMPLOYEE#: DATE: <br /> Date Service C tomple ed (if already completed): SERVICE CODE: `J, PIE: <br /> 1 <br /> Fee Amount: )- vC% Amount Pai ' �—` ('7 n T Payment Date �s <br /> Payment Type Invoice# Check# Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />