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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sri cr7CSs7-1 <br /> OWNER/OPERATOR <br /> Charles Starr CHECK IfBILUNGADDRESS <br /> FACIurT NAYS <br /> SrTEADDRESS 21301 Di N Mann Road Acampo 95220 <br /> Street Number <br /> HOME or NWuNG ADDRESS (H Different from Site Address) <br /> Street Number suve Nme <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN fR LAND USE^�`ICATION# <br /> (209) 329-7791 017-280-10 Pk-of00-v (MS <br /> PHONE is Orr. BOS DISTRICT LOCATION COM <br /> ( ) I C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Charles Starr CHECK ifBILUNGADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 209 329-7791 <br /> HOME or MAILING ADDRESS FAx# <br /> 21301 N Mann Road 1 ) <br /> CITY Acampo STATE CA LP 95220 <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 <br /> or activity will be billed to to my business as identified on this form. <br /> 1 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$tandards ,STATE and F ERALL laws. <br /> APPLICANT'S SIGNATURE: , /,' DATE: A) U <br /> PROPERTY/BUstNEss OWNER OPERATOR/MANAGER O THER AUTHORI7ED AGENT <br /> If APPLICANT is not the BILLING PARTYproof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,)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: 2 F A C-r c AS ce, A c E 6-O tiT�tL 4-'-7-(a,A,) <br /> COMMENTS: <br /> OCT 2 2 2008 <br /> SAN JOAQUIN COUNTY <br /> AccEPTED BY: C', L i C c - EMPLOYEE Z Z DAtItEA1fT�j <br /> ASSIGNED TO: M D 4 EMPLOYEE# s 3 (1,(G, DATE: / 0 2 _/ Gg <br /> Date Service Completed ([f already completed): SERVICE CODE: /S PIE: <br /> Fee Amount: , L) Amount Paida` O Payment Date 2 Z 6 <br /> Payment Type Invoice# Check 8 2 Z— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />