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SAN JOAQUI.J COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c rS�ERvICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEll <br /> GAS i'U <br /> SITE ADDRESS Z �7 PG G��I L �� `OGO✓I q67;--,oq67;--,o7 <br /> ci v <br /> S[reet Number Direction Street Name ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 97,7-3 <br /> 10"4 - ih1I. <br /> Street Number Street Name <br /> CITY <br /> SG` 170&)� $TATE �- ZIP 2 <br /> PHONE#1 4' EXT. APN# LAND USE APPLICATION# <br /> (N ) fta-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH NE# EXT. <br /> f/L G <br /> HOME or MAILING ADDRESS FAX# <br /> 1z_32 �/ ( ) <br /> CITY 1VI 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 Or <br /> 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: vv"'4 4 N DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER 1� OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessef^ijgiq� <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is p�de�T1{�c�f&@Ib <br /> my representative. RECEI <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ' EMPLOYEE#: DATE: I I I Cf <br /> ASSIGNED TO: EMPLOYEE#: ��✓/ DATE: ( (' ( / <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 67 <br /> Date <br /> Fee Amount: Amount Paid Payment Date 7 `/ <br /> Payment Type Invoice# Check# Received By: <br /> V <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />