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SAN JOAQUI,' ' OUNTY ENVIRONMENTAL HEALT) EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GCA 5 ! Cwt-', © C,c) <br /> < G)� <br /> OWNER/OPrT R <br /> n � s- C 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> )P\ � < � bolo c <br /> SITE ADDRESS :� e Vnc�(\? e c <br /> Street Number Direction 1 Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> CP -(\V e C [1 V Q— Street Number Street Name <br /> CITY � STATE � ZIP ' ' 6 ^G P�,\m c:� "l l,� L <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHO E 2 EXT. BOS DISTRICT LOCATION CODE <br /> � �l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> 1 'N 1-�- U U)�! a C- r (.20 "-i b I - 6 S 3 <br /> HOME Or MAILING ADDRESS FAX# <br /> �2 a Q r (�-o5) u b\ - 6 S ti Z <br /> CITY ` Vo C 1 I r% STATE Clc-t ZIP 9 O C <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,Standar STATE and FEDERAL laws. 1 <br /> APPLICA�\T'S SIGNATURE: , DATE: <br /> PROPERTY/BUSINESS OWNER���PERATOR/MANAGERElOTHER AUTHORIZED AGENTIfAPPLICANTie 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 ta e same time it is <br /> provided to me or my representative. PAYME 1 <br /> TYPE OF SERVICE REQUESTED: R <br /> COMMENTS: 0Ec % <br /> %J LUUJ <br /> COUNTY <br /> SAN�Et4�RONiw4T ENT <br /> HEATW <br /> DEPARTM <br /> ACCEPTED BY: �� ,'' C EMPLOYEE#: L�L(y� (f` DATE: <br /> �+ 6 <br /> ASSIGNED TO: Cl �•. �) t EMPLOYEE#: �- '�! DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: Gf�' P 1 E: 7 ?j C. <br /> Fee Amount: _� 't' Amount Paid *�a�Cl y Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden R v <br /> REVISED 11/17/2003 <br />