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SAN JOAQUIN UOUNTYLt'NVIRONMENTALHEALTHDEPARTMENT <br /> r--\ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# "` SERVICE REQUEST# <br /> TUR 5,120a `1(-I & <br /> OWNER I OPERATOR <br /> R' o iv04.F7-i B 1NG ADDRESS <br /> FACILITY NAME of <br /> SITE ADDRESS 360 WE$r AD - A,2&V--t! 641111P 95-Z?/ <br /> Street Number Direction Street Name city Zip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) ��Q �/�S'T 43p I,l/IYQAI )UD. <br /> Street Number Street Name <br /> CITY F F`/v IC STATE �� ZIP <br /> 9SZ3/ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> >�Z-696 /f� 3 �Z6o- zZ PA- . 0 -30 <br /> PHONE#2 EXT. B OS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE#) EXT" <br /> HOME or MAILING ADDRESS FAX# <br /> 0 <br /> Um 37 ( ) <br /> CITY » �� STATE e1+ ZIP pJr p�j <br /> F I� 7 J T! <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 app ' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S T and FE laws, <br /> APPLICANT'S SIGNATURE: �- 3 -06 <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR rMANAGER ❑ OTHER AUTHORIZED AGENTO <br /> IfAPPLICRNT is not the BILLING PARTY proof of au horiZation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locaied 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: .0/1 5U/TAB/L IT sra P — F,XP� ,BEY/E Pt/ <br /> i <br /> COMMS S: <br /> 3j6� _ 2-0 <br /> QpR 0 �p05 RUSH <br /> SWJONQUIN��-Vpa-ppN��v� H�MIr�T <br /> ACCEPTED Y: 0(4 U"C (� EMPLI*E 3 DATE: <br /> ASSIGNED TO: QLt V t p p EMPLOYEE#: pr DATE: L3 t bK�� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �2,L O' <br /> Fee Amount: - 3-P,-pa Amount Paid 3�a, 0 Payment Date 3[n 10 <br /> Payment Type ✓ Invoice# Check _ Received By: v�V <br /> F e . <br /> EHD 48-02-025 5R FQRM:(Goldeff Rod} <br /> REVISED 11/17/2003 ' <br />