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JAN JOAQUIN COUNTYENVIRONMENTAL 1116ALIH VhYAMElract' <br /> SERVICE REQUEST <br /> FACILITY ID# SER VIC REQUEST# <br /> ty PP <br /> Type of Business or Proper . <br /> 6Hs s dA/ l3 D 1W J <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> DEaA// s ec <br /> FACtury NAME <br /> CO-5 Co I <br /> SITE ADDRESS 3As0 Gt_% GfAN f LING / RACy <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) _ J <br /> `/f ? C L Street Number 1_ Street Nam. <br /> CITY STATE ZIP <br /> / 5s ut911 C� 7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (y:U) yaZ 765 <br /> PHONE#2 EXT. HOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR Sim Shag CHECK if BILLING ADDRESS© <br /> BUSINESS NAME PHONEp# ' <br /> W F}y A65 PE lS R y /Co 9pG$o <br /> HOME or MAILING ADDRESS FAx 6 y[O /<'o <br /> o M Iv 1LIE Sul E ( 7/6 ) <br /> 83 <br /> CITY 5'q C/'l9 M Exv �o STC�E 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ Opt04OR/MANAGER ❑ OTHERAUTHORIZEDAGENT,R �aJCC T 11744 er <br /> IfAPPLlC9NT is not the B/LLING 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: R F C E I V E D <br /> COMMENTS: APR 12 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: :71A01110 <br /> : A�j) DATE: <br /> ASSIGNED TO: EMPLOYEE#: O `•V DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE: 6 <br /> Fee Amount: 2Uc' Amount Paid ��� r--�; Payment Date O (o <br /> Payment Type Ll_ Invoice# Check# --1 ( "� Received By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />