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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D•ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST.# <br /> r v -) eco 5 a_66 _7qq Y <br /> WNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FCILITY NAME <br /> G <br /> SITE ADDRESS C /', r <br /> Street Number Dlrecticn / . ��S�ee(N\t ` `-� IN Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> r Street Number Street Name <br /> CITY ST TE ZIP <br /> A <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (?A)014 , <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME G�S ()S PHONE# �/ l <br /> It <br /> / EXT <br /> HOME Or MAILING ADDRESS FAX <br /> ( ) <br /> CI STATE ZIP f <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: DATE: I7r J 1 �o <br /> t <br /> PROPERTY,BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization to Sign is required Tire <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Fmtiio-in I myo 1 �D <br /> COMMENTS: `� <br /> LI ��-�FSI�j MAR 2 5 2116 <br /> SAN JOAQUIN COUNTY <br /> ENVIROIMIENIIAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: U,—b EMPLOYEE#: DATE:-3 <br /> Date Service Completed (if already completed): SERVICE CGDE: b�1 PIE: <br /> Fee Amount: ' — Amount PAidv / Jd v D Payment Date <br /> Payment Type Invoice# Check# Received Bryn: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />