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I SAN JOAQ'-,* .BOUNTY ENVIRONMENTAL HEALTeDEPARTMENT <br /> ' <br /> 4 SERVICE REQUEST <br /> �fype of Business or Property FAZCILITY ID# SERVICE REQUEST# <br /> A4R1eaZ-rum 4-- <br /> 4:: <br /> Samoa a tea <br /> OWNER/OPERATOR L <br /> Slid EA CHECK if BILLING ADDRESS <br /> FACILITY DAME <br /> SITE ADDRESS 3 f '717 Svu TN � �15�'r,4� A49,4D 7 e eV 14S374; <br /> Street Number Dfrection Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 49-7 W Street Number Street Name <br /> CITY A N !-aeA STATE eA ZIP <br /> / "1 -3 <br /> ` PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> F <br /> rPHONE#2 Err. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Da A f el� J�YF r^w O CHECK if BILLING ADDRESS <br /> BUSINESS NAME �v PHONE# �• <br /> CWfs Goivsu rrn/ 03 <br /> s HOME or MAILING ADDRESS FAX# <br /> } CITY u� LOGK STATE G� 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.1 have prepared this appligalion.and that work to be performed will be done in accordance with all SAN JoAQuiN <br /> COUNTY Ordinance Codes,Standards,ST and FED <br /> APPLICANT'S SIGNATURE: 1l <br /> DATE: - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/A ANAGER ❑ OT AuT:oRIZED AGENT <br /> IfAPPL1CANT1s not theB1LL1NGPARTY proof of outhori tion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When ap <br /> "'W'cable, 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 HPALTii DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> I TYPE OF SERVICE REQUESTED: <br /> F ?$ r <br /> N/� F LD�4Di sui-rAa I- 5Tu E --' <br /> COMMENTS: � � RECEIVED _. <br /> - JUN 8 2005 <br /> a IN COUNTY <br /> -{I SAN.IOAC�U <br /> ENVIRONMENTAL <br /> ACCEPTED BY: �! / EMPLOYEE#:} 2_/ <br /> ASSIGNED TO: 14 Lt C,-C--r NS EMPLOYEE#: 1 DATE: e, Wos <br /> Date Service Completed (if already completed): SEhME CODE: �j Z� G� PIE: <br /> i <br /> Fee Amount: I_S=6R?-So Amount Paid �� F --- Payment Date !�! <br /> Payment Type ✓ Invoice# Check# (� L? Received y: <br /> 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />