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1 <br /> E SAN JOAQUI.N COUNTY ENVIRONAZENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> *X1C-aZ-7-URA1- S'ROa 'S'yl /l© <br /> OWNER i OPERATOR <br /> CHECK if BILLING AbDRE55 <br /> /72,2 . PAUL G <br /> FACILITY NAME <br /> SITE ADDRESS14 <br /> Street Number I Direction Street Name c1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4-733 <br /> 733 4ARFCWA 8oT <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PL97,asA N'rv� CA <br /> PHONE#I Ex7--7 APN# LAND USE APPLICATION# <br /> (?2f1 046 -4433, 2-13 - 1q0-o2- <br /> PHONE#2 <br /> PHONE#2 ExT• SOS DISTRICT LOC A1t N ODE <br /> (20 123 - &12-1QS <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> 3 REQUESTpRDD 1 ' c i4e5Aic <br /> 1 /V CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT, <br /> C SPIE CoNSutTirC! <br /> HOME Or MAILING ADDRESS •v • Bvya / (AX# <br /> CITY IrUR <br /> L d 6K <br /> ✓{ +•iT STATE ^, Zip —7iq/ <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 <br /> or 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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards, TE and F L laws. <br /> APPLICANT'S SIGNATURE: FW—e154� DATE,:_ 9"Z/—Q9 <br /> yPROPERTY I Buswuss OWNER El OPERATOR I MANAGER El OTRER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof Df aut orization 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 JOAQUrN COUNTY ENVIRONMENTAL 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: k <br /> M COMMENTS: 7/��� PAY EN <br /> /`�✓* � RECEIVED <br /> AUG 2 1 2009 <br /> SAN JaAQUIN GOt)IVTY <br /> EPIViftONM IJT <br /> ACCEPTED B EMPLOYEE#: 6 q ATE: �I f <br /> ASSIGNED TO: _ } �t O EMPLOYEE#: (r DATE: f <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: fi <br /> Fee Amount: Z 3 Amount Paid -3 O Payment Date &�'t 2-k/ O4` ✓ <br /> Payment Type y yp Invoice# Check# 3 Received By: f. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />