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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PACs ill c"'; T� Q <br /> (� 1 Ktfalc Go. SFeJtcf Gfrfl FC <br /> OWNER/OP RATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> TEQ <br /> SITE ADDRESS I LANF, SfocklO4 9S1,04 <br /> 1�owtN WFf <br /> D 4 O Street Number Direptor,DireStreet Nam. City ZID Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street NumheT Strea!Nama <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> ilC <br /> BUSINESS NAME PHONE# EXT. <br /> ARAot o M1EaN alcnt WG• *o 14-8 u I D3 <br /> HOME or MAILING ADDRESS FAx# <br /> s tr 16to ) 614-Q3 4 <br /> CITY $h LK.daix+U STATE G A ZIP 9 4 S77 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.HrALTii DEpAR'rMr•.N'Ihourly charges associated with this project <br /> or 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 Coder,Standards,SPATE and FEDERAL, laws. <br /> APPLICANT'S SIGNATURE: �/J e�// DArK::/ <br /> PROPERTY/DUSINFSS OWNER❑ F. <br /> OPERATOR ❑ OTHPRAtTHORIZEDAGY1'tld <br /> /fAPPLICAN'1'is not the BILLING PART proofof alltIlOrizat1011 td sign is reyeired Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 ENVIRONMENfAI.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: U [v LENT <br /> COMMENTS: SEC <br /> MAY I Z06 <br /> Qum SAN NVR NME OM t1f <br /> ACCEPTED BY: 2tH 14EMPLOYEE#: NFA ATE' <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed cif already completed):V SERVICECODE: I PI70 <br /> E: <br /> Fee Amount: Amount Paid 76a.R L` t5�i Payment Date 57 0 <br /> Payment Type ✓ invoice# Checkl# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />