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JANJOAQUINCOUNTY ENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> [5k" vs's04.S <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> RME ND Mlle. <br /> FACILITY NAME <br /> K /NE <br /> SITE ADDRESS lip PH yf/cq t 40,O1ZE$5 NO,P.7Y/Of M/3GK✓/LG£A^10 L/ar&-7 ROADS <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> // OL MP/C_ 7-r--2RACE IVF Street Number Street Name <br /> CITY STATE ZIP <br /> Y14n/82io( E SLAA/D W� a <br /> PHONE#1 EXT. APN If LAND USE APPLICATION# <br /> (Zo ) <br /> 37-1-4f!54aaq-170-04 e os �A -�GGfJi3� <br /> PHONE#2 Ean. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> N CHECK If BILLING ADDRESS Er <br /> BUSINESS NAME PHONE# EXT' <br /> Cl-IESNeColV5ut I 1 4,00-/403 <br /> HOME or MAILING ADDRESS FAX# <br /> r. D • Bo 37 g4 ) 4o 0-7-517® <br /> CITY -ruR LOGO STATE (f <br /> A ZIP 9s-39 <br /> BILLING ACKNOWLEDGEMENT: 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 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 appli pion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FEDJ laws. <br /> APPLICANT'S SIGNATURE: DATE::( OG <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ dTHER AUTHORIzED AGENT CJ <br /> If APPLICANT is not the BILLING PARTY 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: SUAFACE SLIBS"AFACC Al .WiNa7/OA/ EF,0AZr V W <br /> COMMENTS: PAYMENT <br /> - a�/tom RECEIVED <br /> FEB - 3 2006 3 / <br /> SAN JOAOUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: DEPART ATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: 3 <br /> Date Service Completed (if already completed): SERVICE CODE: -Z./S P I E: <br /> Fee Amount: 6'' Amount Paid ' .E O Payment Date <br /> Payment Type Invoice# Check# '� Receiv2d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />