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SAN JOAQUIN COUNTYENVIRONMENTAL F1 A.LIn ucrHna •_�. <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property ,/ ' n <br /> FS/DEA(T/A OPEC K v( S <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS D <br /> /Y/k,G MRS. B26lCc A+✓p DANA RG(SSELG <br /> FACILITY NAME <br /> SITE ADDRESS E VIA e'A S/L/NA j5—.5--A 4-0/1 I1-37-0 <br /> a 0 7049 Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LANDUSE APPLICATION# <br /> pal <br /> -0 3 -a <br /> PHONE#2 EXT. 13DISTRICT LO TION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^O C �� CHECK If BILLING ADDRESS <br /> U LPHONE# Ems' <br /> BUSINESS NAME C t r—YdE fJfu G- / <br /> / . // / 3 <br /> HOME or MAILING ADDRESS L V L- FAX# !� <br /> ) 6bS-2x98 <br /> CITY LOG C STATE CIA ZIP p •7 / <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,S)�m and F RALlaws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: T O,-,( E _ 1—c (-), c -A'f , IrL <br /> COMMENTS: RECEIVED C&—X � t T--ff P <br /> ii <br /> OCT 24 2005 <br /> ��-r � SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAl I"DEPART" <br /> ACCEPTED BY: EMPLOYEE JI: 3 2—t DATE: )o 2 q ros-- <br /> ASSIGNED TO: � 1 DY//BL.CLOL EMPLOYEE#: gC)�fS— DATE: �S- <br /> DateServiceCompleted (if already completed): SERVICE CODE: �j(�� P/E: °f2_oi <br /> Fee Amount: 3. OO�Z _ I Amount Paid 0 Payment Date �O Z'-k 10 S <br /> Payment Type ✓ Invoice# Check# ` � Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />