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JANJOAQ`L),.N COUNTYENVIRONMENTALI1EAL'1'H�UE'PAR1erste1 <br /> SERVICE REQUEST <br /> Type of Business or Property v FACILITY ID# SERVICE REQUEST# <br /> C-5-.E STA47-7 <br /> OWNER 1 OPERATOR j <br /> /NJ7 <br /> CHECK If BILLING ADDRESS E] <br /> FACILRY NAME K-WIV_ �Pr <br /> SfEADDRESS <br /> to, 14-R+.")N G Qe-TO N c'S Zb+ <br /> Street Number Direction Street Name city ZIP Cod <br /> HOME orMAILING/ ite Ad <br /> ADDRESS (If Different from dress) <br /> 1�3, G eZm OCAAZ Street Number Street Name <br /> CITY .r�1 , _ ,.}.,v ATE ZIP n q ,Z -6 <br /> PHONE#i Exr. Apry# LAND USE APPLICATON# '1 <br /> 3'7 - ow_t <br /> PHONE#2 ET' BOS DISTRICT LOCATION CODE <br /> l Sl 0 ) vLg - 24 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E�' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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 /> �� 1 <br /> �� r7 <br /> APPLICANT'S SIGNATURE: 1 I� ot- may'" DATE: 3/ / <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT El <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 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. S7— <br /> TYPE OF SERVICE REQUESTED: C-0 ALS Lf,L'TPI-77 O rJ RECE <br /> Wnl <br /> COMMENTS. MAR 2 8 2007 <br /> SAN JOAQUIN COENVIRONM6NTUNTY <br /> HEALTH DE ARA L <br /> ACCEPTED BY: O L I OC- (" EMPLOYEE#: C)3 DATE: 3 <br /> 91 <br /> ASSIGNED TO: K..N EMPLOYEE#: SS DATE: 3 �_ U� <br /> Date Service Completed (if already completed): SERVICE CODE: CV11` PIE: _23 , (/ <br /> Fee Amount: '-d Amount Paid Payment Date <br /> Payment Type L j' Invoice# Check# LReceived By: H (� <br /> EHD 48-02-025 �l_ ` .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />