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1 ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9 3,39' <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> ecen \Ce cve � - <br /> SITE ADDRESS ( eC� �-� &)n t? 7np <br /> 55 �G\ TStreeln ber Direction Street Name Ci Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2 12, F A' Street Number Street Name <br /> CITY l O�i \� STATE ZIP <br /> C <br /> -1 ` ''l c.� S Z057 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> �v <br /> BUSINESS NAME PHONE# EXT. <br /> GC 1C.C dee <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �Tj^ , 5 ?-O(' 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �/l <br /> / //� <br /> PROPERTY/BUSINESS OWNER VOPERATOR/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 prr�ided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: /��I I( GIC I + I S <br /> COMMENTS: AR <br /> %40 , ZOJg <br /> U� <br /> �MFbr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ' /` EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: o&) <br /> P 1 E:1 3 <br /> Fee Amount: 'U O Amount PaiPayment Date 44// <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />