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SANJOA 'd COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> V SERVICE REQUEST <br /> Type of Business or Property <JAGIUTY-111#1 SERVICE REQUEST# <br /> �✓• o� I� U U <br /> OWN OPERATOR CHECK if BILLING ADDRESS <br /> IcItC. <br /> FACILnY NAME <br /> SITE ADDRESS -T <br /> GC <br /> 1 Street Number Direction A A! 4 I✓ \ treet e � <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> f , � <br /> `t C- Street Number <br /> CITY \ STATE zip <br /> PHONE#'I EXT' LAND USE APPLICATION# <br /> 7-cfete 003 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C /'�J CHECK If BILLING ADDRESS <br /> �- <br /> BUSINESS NAME PHONE# EXT. <br /> ( ) <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 /> 1 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 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 <br /> above site address, hereby authorize the release of any and all results, geoteclutical 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: f�;Atk <br /> COMMENTS: RECE�� <br /> pEC 1 �2003 <br /> JOAOVM C� N-N <br /> SN'l 1- <br /> NvtRONlu PARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE. <br /> ASSIGNED TO: *7vu /3 EMPLOYEE#: LL/�L� DATE: �Z l <br /> Date Service Completed (if alr(ady completed): SERVICE CODE: T�A� 1 E: <br /> Fee Amount: GCC, Amount Paid +fi �tloS't�-0 Payment Date <br /> Payment Type Invoice# Check# 1 L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />