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OAlN JVAljU11N II-4-111-In1 Y 11INVIRIJIN1V1L1NIAL HEALIHiJEVAKIINILD41 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUUES1# <br /> /OEn/T/LFL 5fcoq I LI I tJ <br /> OWNER/ OPERATOR <br /> § Su/INDEV �7/L Gd/tI CHECK if BILLING ADDRESsEl <br /> P.4R1"11V0se <br /> FACILITY NAME <br /> SITEADDRESS 023&07 SOurN '1/,4Nf'Ev K�OI T.PAC� 9.530� <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -4`7 ( /e,Q/N WE 1-L -Pe/VE <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S,4N TOTE: C'A 95/3 - <br /> PHONE#'I EXT. APN# LAND USE APPLICATION If <br /> 1¢081 -�7d - q,709 ao -i3o - i PA -O4 47S <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) C <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> T � CHECK if BILLING ADDRESS <br /> BUSINESS NAME L PHONE# EXT' <br /> c F-SN,EGON1c!( Tin/ I 140 <br /> HOME Or MAILING ADDRESS FAx# <br /> �0 - x 37 <br /> r3094 <br /> CITY �u RL OCK $TATE ( >A ZIP 9J 3 <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 lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE an DERAL laws. <br /> APPLICANT'S SIGNATURE: ZdleDATE: Z�f'D' <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAG OTHER AUTHORIZED AGENT® <br /> IfAPPL/cANT is not the BILLING PARTY p oofojauthorization 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: SOIL �u/f,4B/L/T S>7,{ El//�W RECEIVED <br /> COMMENTS: av (Ga..-aJ ` (yara�, 1 JAN 2 4 2007 <br /> SAN JOAQUIN COUNTY <br /> IAW ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ^ <br /> ACCEPTED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: J I O V l 6 5 EMPLOYEE#: D DATE: cI <br /> Date Service Completed (if already completed): SERVICE CODE: J 47 PIE: <br /> Fee Amount: �� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ,§R FORIU(Goldin Rid) <br /> REVISED 11/17/2003 <br />