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SAN JOAQUIN COUNTY ENVIRI-NMENTAL HEALTr' DEPARTMENT <br /> NOVO SERVIC{`REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> aeaAl Latif ae0gq`7-75 <br /> OWNER/OPERATOR <br /> Johr /V*-�/ <br /> FACILITY NAME ^ ra� • CHECK If BILLING ADDRESS <br /> � <br /> // N/ s <br /> Qtll/e�• /' �' <br /> SITE ADDRESS //. O /e 1�"{� � ���• ?5240 <br /> Street Number Direction GT Street Name City de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sbeet Name <br /> CITY STATE ZIP <br /> PHONE#1 EU, APN# LAND USE APPLICATION# <br /> (Zo9) 93/- oGs/ D59 - 2oa -oG vA- D6-�39lins) <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> JO� J r, / �-i�rO� • CHECK If BILLING ADDRESS <br /> BUSINESS NAME T ! /4 PHONE# Exr. <br /> .Sam 9) 93/- 065/ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: M Xz �l4l• <br /> � DATE: <br /> PROPERTY/BUSINESS OWNER% V OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /fAPPLICANT 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 <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: CP— T <br /> COMMENTS: !2//2le6— / O� I-ILUEIVED <br /> M . 'er. ,gyp � NOV 1 0 2005 <br /> Q;-ASAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME <br /> ACCEPTED EMPLOYEE#: DATE: a <br /> ASSIGNED TO: EMPLOYEE#: 7 / DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: <br /> Fee Amount: Amount Paid \ Q(o-po Payment Date \\ (6/0-S <br /> Payment Type i/ Invoice# Check If L� 2 7� Received By: 0� G <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />