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SAN JOA Q _UI� BOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> . <br /> ' FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> CHECK if BILLING ADDRESS <br /> OWNER I OPERATOR Michael Serrato <br /> FACILITY NAME <br /> 113 <br /> F Grace Christian Church <br /> SITE ADDRESS 5555 VV Grant Line Road Tracy Ci zl Code <br /> Street Number Direction Street Name <br />` HOME Or MAILING ADDRESS (If Different from Site Address) <br /> E Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#t Ext. APN# LAND USE APPLICATION# <br /> ( l <br /> HONE <br /> ExT• BOS DISTRICT LOCATION CODE <br /> ( r <br />{' CONTRACTOR 1 SERVICE REQUESTOR <br /> r <br /> EBUSINESS <br /> R CHECK if BILLING ADDRESS <br /> PHONE# Exr. <br /> AME <br /> FAx# <br /> HOME or(MAILING ADDRESS <br /> STATE Zip <br /> CITY <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not theBILLINN 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. <br /> TYPE OF SERVICE REQUESTED: Engineered Septic System (Revision <br /> COMMENTS: <br /> APPROVED BY: EMPLOYEE fi: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br /> r <br />