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FROM :B.Z.SERVICESTATION MAINT 7lNCE FAX NO. :916 371 2540 dug. 11 2006 01:22PM P3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property RVICE REQUEST#AD <br /> OWNER I OPERATOR CHECK H BILLING ADDRESS to <br /> FACILITY NAME <br /> SITEAonw5s rl j ( Z{llY� C� Dl0 <br /> Pfi v�. a <br /> 8trwt ilmmpsr C° <br /> HOME or MAILING ADDRESS (If Different from$Ite Address) <br /> sve t renSwed Namy <br /> CITY STATE Zip <br /> PEW€#1 E'T- APN s 4IBOS <br /> USE APPLICATION 19 <br /> PHONE 02 Exr. DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RFOUESTOR ;1 tNA\I \1 ` O <br /> lATDD CHECK I}BILLINO ADDRESS❑ <br /> BusiNess NAME `d <br /> HOME or MAILING ADDRESS FAxN <br /> Cm VAuLk <br /> STATE Yc Zip i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEYARrMHNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> L also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN.)OAQUIN <br /> COONI'Y Ordinance Codtas,.SYandards,STATE an4 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: "Qla <br /> PmtrcNTv/BUSINESS OWNER❑ OPERATOR/MANAGrit 17 OTlIKKA(ITRORIZEDAGENT)p <br /> ff APPLICANT is tint the BILLING PARjy proof of authorization to sign is required/� rtrlf <br /> AUTHORIZATION TO RELEASE LNFORMATLON: When appdcable, l.•the owner or operator of the property located at the <br /> above site address, hereby audtorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUN'CY ENVIRONMENTAL.HBALTtl DRPAR'rMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REDUEsTEG: <br /> ComNENIS: <br /> ACCEPTED BY: EMPLOYEE#: DATE <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: Fir: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Recelved By: <br /> EHD 4"2-025 SR FORM(Golden Rad) <br /> REVISED 1 tf1712DO3 <br />