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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTII DEPARTMENT <br /> i , SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V4CAA/-F S2oo4a�¢� <br /> OWNER/OPERATOR C <br /> R. ELL f/ Q CHECK N BILLING ADDRESS <br /> FACILITY NAME - <br /> SnE ADDRESS S �9�4 C,Q r2 -A Q(,� //j/�'Gj .�// <br /> 3/s7 S S met Number Dire tion $lrtet Name r— <br /> C. Zi COEe <br /> HOME OrfMARMG ADDRESS (If Different from Site Address) r` C <br /> T t70 � Street Number `I-F-✓L A�� <br /> CITY Street Name <br /> T7ZAI;g <br /> STATE tom-+ ZIP <br /> PHONE#1 ` Exr. APN# LAND USE APPLICATION# —7 <br /> I 1 � 3S - 9 f O — O �/ I� <br /> PHONE#2 Ezr. <br /> BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'fes, w ' <br /> �/ 0/�' CHECK If BILLMG ADDRESS <br /> BUSINESS NAME �� PHONE Ear <br /> C�t7 Co s t—r1.✓( �olv8- 3 <br /> HOME or MAILING ADDRESS FAX III <br /> CITY 3214 <br /> STATE /A ZIP r / <br /> BILLING A "OWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this apph ion and tha work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY OrdinanceCodes,Standards, and FED S. <br /> APPLICANT'S SIGNATURE: s-- <br /> PROPERTY <br /> � G+^O S <br /> DATE:_ .J t/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/D NAGER ❑ OTHE AUTHORIZEDAGENT� <br /> If APPLICAYT is not the BILLING PARTY proojojauthariza 'on to sign is required Title <br /> AUT11ORI7-ATION 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 environntental/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: P TE ✓/ . <br /> couaENrs: NT <br /> 11-2 CEI ED <br /> AY 9 2005 <br /> lQo .,AN JOAQUIN COUNTY <br /> ACCEPTED BY: CNVIRONM NTAL <br /> EMPLOYEE#: TMENT <br /> /� " Z / DATE: 5- ().S <br /> ASSIGNED TO: �OL'rrNS EMPLOYEE#: �1 <br /> Date Service Completed (N already completed): 8 S � <br /> - SERVICE CODEDE DATE: (c, <br /> :�su_ ei 2 Z PIE: <br /> Fee AMOunt: -C <br /> (81c �_ i'i2-, � I Amount Pald 3.7 i. u U payment Date <br /> Payment Type Co Invoice# Check# <br /> 3 t G' Received By: �Z <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />