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NAN JOAQUIN(AUNTYENVIRONMENTALt1EAL'1'HJJEFA2RI1VU Ptt <br /> SERVICE REQUEST <br /> Type of Busin SS or Prop e� FACILITY ID# SERVIIC EQUEST# <br /> OWNER/OPE TOR /i <br /> (" ,,/ CHECK If BILLING ADDRESS <br /> CIA <br /> !/ <br /> FACILITY NAME 1 laC ,/ Q <br /> SITE ADDRESS /(1// r70 Cam 12A,CG, [,4Y1rOp /1333 <br /> Street Number Direction Street Name city c' Zip ceft <br /> HOME or MAILING DRESS (If <br /> Different from Site Adm{ <br /> dress) <br /> •� j;Jt�Z... /L �/ • Street Number Street Name <br /> CITY �r•f 1T arS / � � // STATE ZIP <br /> 12,04 /0719 <br /> PHONE#1 E)"• APN# 3 0 LAND USE APPLICATION# <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> 5-193 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> Q <br /> BUSINESS NAME PHONE# ' <br /> 1616 I V 5111raclaite s Sac. 1161- 4,337 <br /> HOME Or MAILING ADDRESS FAX# 46/- <br /> /- / S//c? <br /> CITY STATE zip QJ- 2/1r-- <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,SIATE and FEDERAL laws. // (7 <br /> APPLICANT'S SIGNATURE: , DATE: l�-L�� d1S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /)j[p• IQ,�� 37- 77/Lila <br /> If APPLICANT 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, geotechnical data and/or environmentallsite 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. /r- <br /> NT <br /> TYPE OF SERVICE REQUESTED: �S 7— /�� r—(T REC P: <br /> COMMENTS: <br /> JUN 3 0 2008 <br /> 'N COU <br /> NEN H NAR ENT <br /> ACCEPTED BY: ( U ( EMPLOYEE#: Z/ DATE: <br /> ASSIGNED TO: N (Q L'( EMPLOYEE M DATE: 3 6 U'6 <br /> Date Service Completed (if already completed): SERVICE CODE: f P I E:Z <br /> Fee Amount: E)0 Amount Paid 'a C7 Payment Date 6(201/ 0 <br /> Payment Type Invoice# Check# `3 O 2-C) Received By: ^f <br /> EHD 48-02-025 " ,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />