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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r, SERVICE REQUEST <br /> Type of Business or Property FACILITY Ib# \ - SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> e`C• Q , e• /�AeM5 I-V)Z . ee/n/r A&IW, 6 K CHECK If BILLING ADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS ��Saz 'J l t/EST �;Ae~ /SGA/VP Ra/4 D : Tn cxrcw <br /> 9.sz3� <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> a • Street Number Street Name <br /> CITY <br /> � STATE � ZIP 9�Z3 <br /> PHONE#1 EXT. Aa PN# LAND USE APPLICATION# <br /> ( �9 41*4 -39�d 1 - a4v-W a A1A <br /> PHONE#2 ExT• B OS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DoH /1 /jc.t�� CHECK If BILLING ADDRESS <br /> BUSINESS NAME C/h' J PHONE# ExT• <br /> HOME or MAILING ADDRESS FAx# <br /> 3px 3 <br /> CITY R LOGIC STATE ZIP 953 <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 applipation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S E and Ff,.DYQ laws. <br /> APPLICANT'S SIGNATURE: DATE: 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LrJ <br /> IfAPPLICANT is not theBILLINGPAR77Z proof of a horization 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. <br /> TYPE OF SERVICE REQUESTED: Sa/// ^SU/7-A$IL/ — xPED r TF-p ESI <br /> COMMENTS: ��Zr�fJAMpt�f 71a FkE <br /> "� CEIVED <br /> COY d z�,n�„ <br /> �`� MAR 1 2006 <br /> 6-7 Ip COUNN <br /> SAN.]OAQU1S3E1`1�Eta <br /> �NV1FtON� <br /> ACCEPTED BY: <,�J_,/` EMPLOYEE#: H� ATE: <br /> ASSIGNED TO: �--��!/ EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 4�p P!E:z6b� <br /> Fee Amount: ,IZ t� Amoun#Paid 37�. Q Payment Date 3 6 <br /> Payment Type L/ Invoice# Check# ;!,y Received By: <br /> EHD 48-02-025 SR FQFtM(Golden Rod} '" <br /> REVISED 1111712003 <br />