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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business pr Property FACILITY ID# -,-SE-RYICE REQUEST# <br /> T d k <br /> MT, <br /> OENEW� <br /> R 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> nhAetrV FQJy-,9�AP7- <br /> FACP-rTY NAME fr ' ff� <br /> SITE ADDRESS 700 Souter ZA 951-36 <br /> Street Number Direction Street Name Ci Zip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S& L-- Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> (zdi ) 1 t 7 1 -o - o` <br /> PHONE#; • � � !��� EXT; � 805 DISTRICT (_OCATiON CODE <br /> C..t�[/Jt C G p( c( <br /> CONTRACTOR/ SERVICE REQUESTO <br /> REQUESTOR / <br /> CS O G. L e A' 11 ��� CHECK If BILLING ADDRESS C� <br /> BuSIN ss NAME PHONE# Eu. <br /> yJ c rn T>e • { 6Zo9 r- ?4P <br /> HOME or MAILING ADDRESS FAx# <br /> 31W W. T ti . S - t#too (?,di) Tt4 ? — ? <br /> CITY / � STATE ZIP 1?5- 1 C <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 7oAQUIN <br /> COUNTY Ordinance Codes,Stand ATE and7F -��aws. <br /> APPLICANT'S SIGNATURE: t DATE: 91S12-007 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑. OTHER AUTHORIZED AGENT LA.Eo i rtem�tiA >Ci— <br /> IfAPPL1CANT is not the BiLLnvG PARTY,proof of authorization to sign is required <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 IOAQUIN 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: /��/� <br /> COMMENTS: C / Lj j�r . / JrD/r'�'? 3 /17�Q� ECEIVED <br /> K-F 3D r MAR - 5 2007 <br /> SAN.lOAQON <br /> ` ENVIRONMENTAL 7Y <br /> NE4LTf f DEpA <br /> ACCEPTED BY: Gti L j v�E Q�_ EMPLOYEE#: C)3-_7 ( DATE: <br /> ASSIGNEE TO: (ILJo �-T � EMPLOYEE#: -73-7 DATE: 3 <br /> Date Service Completed (if already Completed): SERVICE CODE: 3 /s P l E. <br /> Pee Amount: `cj� Amount Paid 'G� Payment Date <br /> Payment Type L� invoice# Check# a D Received By: 6 — <br /> EHD 4$-42-025 SR .ORIF( old n Frod)' <br /> REVISED 11/1712003 <br />