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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST#/ <br />G� S S '� � � <br />F <br />OWNER I OPERATOR <br />- <br />( o \A ee+ 5,n <br />CHECK if BILLING ADDRESS <br />FACILITY NAME O P <br />SERVICE CODE: <br />SITE ADDRESS <br />3 O <br />Fee Amount: <br />cb /0'1 °7 <br />!�� <br />l�� �'1 <br />9-5.3il)l <br />r StreatNumher <br />Direction <br />/ <br />streetName <br />C <br />Zip Code <br />HOME or MAILING ADDRESS (If Different (ram Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Ems• <br />i 1 <br />APN # <br />LAND USE APPLICATION # <br />RHONE 02 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR G+va� C. [ 11} S I.wI I^" f e <br />CHECK If BILLING ADIIRESS ❑ <br />BUSINESS NAM� PHONE I-7 EXT. <br />?QiMQYI� �"IY01e�1,r� S rvi r-eI QAC. 9z9 4 7o-0, <br />HOME or MAILING ADDRESS FAX <br />3 6 t C { <br />CITY DL' t0 STATE CIA ZIP g (150 1 + <br />eSILLINt! Ak;rNUVVLERGhMENT: t, 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 OT <br />activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done to accordance with ail SAN JOAOUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERA. <br />APPLICANT'S SIGNATURE --t t DATE: p _ % <br />PROPERTY t BUSINESS OWNER OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />M APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titre <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 environmentaYsite assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time it is provided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: o , place Cel FF -5 <br />C�-I) oe ",) ��S <br />f/C�r/LJ � eovHr�ly Gv�� <br />ACCEPTED BY: <br />s1�c,1skfi oWf w, 71, <br />w. <br />mac.( L�✓Cr%r�� /��Pr/��I�dvr �>v`/��P.�r���iiJlc� <br />EMPLOYEE #: DATE; <br />ASSIGNED TO: <br />EMPLOYEE 4: DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE. <br />Fee Amount: <br />Amount Paid <br />Raymeni Date <br />Payment Type <br />invoice # <br />Check # Received By: <br />EHD 48-02-025 5R FORM (Golden Rad) <br />07/17108 <br />