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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S g3 <br /> OWNER/OPERATOR GG+Dr <br /> CHECK If BILLING AODRESSO <br /> FACILITY NAME i/` Tt' Te� Oo t� <br /> SITE ADDRESS N Itll�i ((I, t+ ^ ' c�01m <br /> �1 <br /> �l/rU Street Number Dlrectlon l/Ul• treet Name Ca 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ETT• APN# LAND USE APPLICATION# <br /> (zo ) 3 <br /> PHONE#2 •� ETT• BOS DISTRICT LOCATION CODE <br /> ( ) lJ y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME y ` PHONE# ETT <br /> ( 6 <br /> HOME or MAILING ADDRESS FAX# <br /> I l ( l <br /> CITY C STATE p ZIP /n D <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, STATE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 13 <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 <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. p <br /> AXa- <br /> TYPE OF SERVICE REQUESTED: e nS ` RF l r <br /> COMMENTS: D <br /> Nr4Y 10 <br /> J0AQUtN Q 2� <br /> H THo Pqf�,nN AI <br /> ACCEPTED BY: 1121 A krO EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 3 Jr/I/ DATE: lO <br /> Date Service Completed (if already completed): SERVICE CODE:IIYY PIE: II/x,03 <br /> Fee Amount: V Amount Paid 6• ! Payment Date D 2 <br /> Payment Type Invoice# Ghe6 t�f Z U (Q Received By: <br /> REVISED 11/1712003 <br /> EHD 48-02-025 r SR FORM(Golden Rod) <br /> �� �� /'� <br />