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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ WL40 <br /> LTNC CHECK if BILLING ADDRESS <br /> FAMITY NAN_ <br /> SITE ADORE 5 <br /> NI'StreLK�mber Direction I Street flame <br /> HOME or MAILIIG ADDRESS (It Different from Site Address) <br /> 28 I IIS f+ <br /> F, Street Nurrbrr Street Name <br /> STATE�� ZIP <br /> PHONE#1 -� ExT. APNr LAND USE APPLICATION# <br /> (�q)'y%el <br /> PHONE#2 Ex.. BOS DISTRICT LOCATION CODE <br /> ( ) 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Glenn Paredes CHECK if BILLING ADORGSs[I <br /> BUSINESS NAE PHONEP ExT. <br /> II B&T Service Station Contractors 805 235-6442 1002 <br /> HOME or MAILING ADDRESS FAx# <br /> 630 South Frontage Road (805 ) 929-8948 <br /> CITY Nip mo STATE CA ZIP 93444 <br /> I <br /> BILLING ACKNOWLEDGEMENT: I, the urdersianed property or business owner, operator or authorized agent of same, <br /> acknovAedgei that all site and/or project specific ENV RONMENTAL HEALTH DEPARTMENT hourly charges associated with this protect or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certifyjthat I have prepared this application and that the work to be performed wili be done in accordance with all SAN JOAQUIN <br /> COUNTY OrdihIance Codes,5randards E andF ERAL laws. <br /> APPLICANrfIS SIGNATURE: <br /> DATE: � <br /> PROPERTY I E USINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site addres , hereby authorize the release of any and all results,geotechnical data and/or environmental/site aa,%ebsment information <br /> to the SAN U AQUIN COUNTY ENVIRONNiENTAL HEALTH DEPARTMENT as Soon as It is available and at the same tirne it is provided to me or <br /> my representative. <br /> TYPE OF SERE REQUESTED: <br /> COMMENTS: <br /> _..1 C <br /> J <br /> ACCEPTED B I EMPLOYEE#: I GATE: <br /> ASSIGNED T0: EAtPLOYEE DATE: V - <br /> i. - <br /> Date Servic Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Tj pe Invoice# Check# I Received By: <br /> EHD 48-C2-0 5 <br /> 07117/08 SIR FORM(Golden Rod) <br />