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A1H1\ JVH�[U1l� l.VVll11 L'11V11N"1'1V1L'1\1t1 11GHL111 LL.Hi�u�ia.�aTl <br /> ' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RIt-az u <br /> OWNER/OPERATOR <br /> Mg. 1/ALDE'✓/11A 2 OLSOit/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS o26074, 1VDa7N /L(A(G&V/6GE 7z t> • CZ,5F/7fWM q57a..27 <br /> Street Number Direction Street Name city 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# LAND USE APPLICATION# <br /> ( ' 33 - /97-2 -37 <br /> PHONE#2 EXT. BOS DISTRICT LOCATONCODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR N C/��SNE7CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Elr' <br /> G SNF u� /ic/C Gd B-14 03 <br /> HOME Or MAILING ADDRESS FA%# <br /> - oBOK ( ) io6 B -ZS 98 <br /> CITY �Gf R LO G/C STATE ZIP 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 apply tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S f and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: afo <br /> PROPERTY/BUSINESS OWNER❑ OPF.RATO /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PAR TP proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: /r4-8a /T STGCD 1//F1�1:/ RECEIVED <br /> COMMENTS: G/ b AUG 2 5 2006 <br /> SAN JOAQUIN COUNTY <br /> Q w t <br /> vw' • ENVIRONMENTAL <br /> r-'-VI�,w/� HEALTH DEPARTMENT <br /> ACCEPTED BY: IJ EMPLOYEE#: DATE: <br /> ASSIGNED TO: at EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: L41 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4&02-025 - .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />