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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7`,cf 3� <br /> OWNER/OPERAT <br /> Gt r!� <br /> cht S CHECK if BILLING ADDRESS 19 <br /> FACILITY NAME <br /> 1 GWl t C.e— <br /> SITE ADDRESS /5 3 <br /> Street Number Direction �+ Si're-SteetName CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5 ti '1Cti dV Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME P ONE EXT. <br /> () <br /> HOME or MAILING ADDRESS 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 /> 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, TE and �EKDAIL laws. <br /> 11 <br /> APPLICANT'S SIGNATURE: DATE: — 3— Z O if <br /> PROPERTY/BUSINESS OWNER# OPERATOR/MANAG R ❑ 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 assessmerrmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is prq�d�V%9—gr <br /> my representative. `` /� -•,cN� <br /> TYPE OF SERVICE REQUESTED: �OO A VAN ,\@ Z <br /> COMMENTS: 5,�,,,•,J ?0� <br /> cotj <br /> EA,yRTM NT <br /> ACCEPTED BY: � ��A EMPLOYEE#: DATE: <br /> I <br /> ASSIGNED TO: CLti�y„� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 ' PIE: <br /> Fee Amount: l �, 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 />