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SEP -06-2007 THU 09:49 AM RVR <br />FAX N0. 303_984 1119 P. 03 <br />-1.f <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE. REQUEST <br />TVoe of Business or Prntwdv <br />CONTRACTOR/ SERVICE REQUESTOR <br />HE UES70f r'. 'w, / ,y% . r -- <br />( lwl 1C/�A-I{' <br />I-AULN T IU 1 SERVICE REQUEST# <br />BIfir AAE <br />/ � � , <br />PHONE E..'. <br />(Iwo) Filb _ 2.92 2 <br />OWNER / PERATObt''t <br />FAx# <br />( > 54I --338 1 <br />CITY STATE I /1 ZIP <br />CHECK N BILLING ADDREss <br />�1• <br />ILfIV IrxME <br />U)m III CD <br />DA.aC.� <br />SrrEADDRESS <br />f% <br />Stmn, Number Dimrla <br />EOf MAILINGA DRESS (If Differard from SiWAddress) <br />treat Name -TO7 I ` 0=5 <br />oR r c°�° <br />L'oraeo�aL Plc <br />. <br />EMPLOYEE #; <br />(,• <br />Stre�a�N mpe, R !,Name <br />Date Service Completed (if already completed): <br />STATE x <br />�a' 71PP <br />f <br />PHONE #1 Fx. APN# <br />(2.10) A/hl Vn <br />LAND <br />PHONE #2 Err. <br />BOS DISTRICT <br />LO CATION COOS <br />CONTRACTOR/ SERVICE REQUESTOR <br />HE UES70f r'. 'w, / ,y% . r -- <br />( lwl 1C/�A-I{' <br />Q�>l'"1 (�(,�{ / CHECK If BauNr, AnnHess <br />BIfir AAE <br />/ � � , <br />PHONE E..'. <br />(Iwo) Filb _ 2.92 2 <br />Eor MAILIN DD S. � <br />W41J � <br />FAx# <br />( > 54I --338 1 <br />CITY STATE I /1 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 DEPARTMEN Ihourly charges associnted with this project <br />or activity will be billed to me or my business as identified on this fomt. <br />I also certify that I have prepared this applica ' R e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance C odes, Slandard'&c . d :E E aws. y <br />APPLICANT'S SIGNATIIR DAT'F.- <br />PROPERTY/ BUSINESSOWNER❑ Cn :R /NIANACER ❑ OTHERAuruOap.Eo AGENTy-J /" L . <br />IfAPP/JCANT is not the /11f.L/Nei h.IRTF proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located it (fie <br />above site address, hereby authorim the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HIiAI.TH DEPARTML:Nl- as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REGUESTED: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />SEP 6 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY.7-1 <br />EMPLOYEE 1: <br />f% <br />q AAT ENT <br />ASSIGNED TO: / U <br />k/04111 <br />EMPLOYEE #; <br />DATE: <br />Date Service Completed (if already completed): <br />SERWCE CODE: A <br />PIE: <br />Fee Amount: Z <br />Amount Paid <br />Pay en Date <br />Payment Type L,,,—Invoice# <br />Check# �' <br />3$ O <br />Rocei tl <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />