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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C �r NO-Ai SF,u)-1 g 3a <br /> r3'vNER 1®77b <br /> A- Iy-pp <br /> B40-N Dll/'� CHECK If BILLING ADDRESS C &FACILITY NAME ` L`J 1 ' — ,1. L'^�_ <br /> 1 <br /> SITE ADDRESS `- <br /> G p moi ; T - 92iStreet Number Direction Street Name Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> l <br /> 1� Street Number Street Name <br /> CITY T�T E ZIP L- rci <br /> PHONE#1 1 EXT. APN# L-AND USE APPLICATION# <br /> PHONE#2 EXT. BdS DISTRICT LOCATION 1`At <br /> r SCS VFX <br /> CONTRACTOR/ SERVICE REQUESTOR Tli 0 <br /> REQUES R <br /> iO ?016 <br /> CHECK If BI LIN O <br /> U <br /> BUSINESS NAM 1 �� _ PHONE# DE q�N� <br /> S = ( ) FNr <br /> NOME or MAILING ADDRESSFAX# <br /> ( ) <br /> CITY \ , \ TATE ZIP ' )� <br /> BILLING ACKNOWLECGErthENT: 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. I <br /> —� I l <br /> AP LiCAN T'J SiGNAT URE: DATE: <br /> �y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ 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 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: GQ <br /> COMMENTS: �r ' p <br /> ACCEPTED BY: ,fA EMPLOYEE#: DATE: b <br /> ASSIGNED TO: A4*1 Q�r ErAPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C <br /> P": <br /> Fee Amount: , Amount P` Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />