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SAN JOAQUIOUNTY ENVIRONMENTAL HEALT&EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> . GAO S4"QV� t7 � /q3 <br /> OWN /OPERATOR <br /> CHECK If BILLING ADDRESS <br /> CA <br /> FACILITY NAM <br /> SITE ADDRESS t 1,4 f <br /> Street Number Direction ry Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 1154-1 <br /> CITY STATE ri up <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` � V <br /> v CHECK If BILLING ADDRESS <br /> BUSINESS NAME P N Ext. <br /> HOME or MAILING ADDRESS c FAX# <br /> 1� 6 ( yo - 3 4a - 050 <br /> CITY STATE ZIP G <br /> BILLING AC OWLEDGEMENT: 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 prepa this lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,St ndards, ST nd DERAL S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGEN <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: _�- ®� t�- Fc f �✓� 1 � <br /> COMMENTS: � 'o � 'j(� � � �� Eb <br /> �Q a�r� J ll 21 2008 <br /> NOUNTY <br /> TMAL <br /> RUSH <br /> FNT <br /> ACCEPTED BY: (�Lt L+Ogc 10-- 4 EMPLOYEE#: ©3 DATE: ,f L l 0 <br /> ASSIGNED TO: A EMPLOYEE#: -75"3 DATE: P Q <br /> Date Service Completed (if already completeg. 2�� SERVICE CODE: P I E: Z3 <br /> Fee Amount: i s a p _ mount Paid t 2- , s 0 Payment Date 2I 8 <br /> Payment Type invoice# Check# 35 Received By: �-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />