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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gZ32 <br /> OWNER i OPERATOR <br /> 1 ck r•� CHECK If BILLING ADDRESS <br /> FACILITY NAME G U� (/t �/I� q 1in (J <br /> SITE ADDRESS l, W l t' ` <br /> Street Number actio Street Name CIN ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �OG lbr) STATE ZIP Z�O <br /> PHONE#1 EXT. APN# LAND USEAPPLICATION# <br /> ( a2) (� D <br /> PHONE#2 E%i. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR _ �7 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 P v PHONE# ExT. <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 <br /> or 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, STAT•.and FEDERA laws. <br /> APPLICANT'S SIGNATURE: � �jt DATE: /—7 <br /> — /LI — Z( <br /> PROPERTY/BUSINESS OWNER 9 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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/siossment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th <br /> provided to me or my representative. / Cr� <br /> TYPE OF SERVICE REQUESTED: �Q VthkGI& (,OVIW ,IU <br /> COMMENTS: <br /> Lo�lXVEPARTT�N <br /> 'SENT <br /> ACCEPTED BY: EMPLOYEE#: 1-7 DATE: 1 2,0 <br /> ASSIGNEDTO: V I.`*w AztvedLQ EMPLOYEE#: 6tO clZ DATE: '(L.' <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: U <br /> Fee Amount 2 Amount Paid �S�.DD I <br /> Payment D to 1�/yam <br /> Payment Type VkS�- Invoice# Check# I I R 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />