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:SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> on 2 <br /> OWNER/OPERATOR CHECK if BILLING ADDRES <br /> Edward and George Garcia <br /> FACILITY NAME Mr. Bonds Bail Bonds <br /> SITEADDRESS 33 VV Mathews Road French Camp <br /> Street Number Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)3108 Cherryland Avenue <br /> Street Number Stree Name <br /> CITY Stockton STATE CA ZIP 95215 <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> ( I 193-160-26 - 6> —ppgJ� <br /> PHONE#2 EXT. tr BOS DISTRICT LOCATION CODE <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR OJ <br /> REQUESTOR C CHECK if BILLING ADDRESS W <br /> BUSINESS NAME O / PHO Ex. \� <br /> HOME or MAILING ADDRESS FAx# „D <br /> r7-1061' - CO V <br /> CIT• STATE ZIP5 Z07 <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 <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 application and that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE L 1 S. <br /> APPLICANT'S SIGNATURE: Z'A DATE: d <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ec <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 t0 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: A) I T-”-r it Lv t-b / r-' L S ru -3 1/ t L S 1=t- C T-4 ,6/L-I i <br /> COMMENTS: <br /> 3 ro E AJ <br /> ( S 'FRECEIVED srF ESl N <br /> e9 ) <br /> MAR 6 2009 <br /> APPROVED BY: Q L L t EMPLOYEE#: p NMENTAL DATE: <br /> ASSIGNED TO: T S I O'T QEMPLOYEE#: �'O`(SDATE: i 15(U <br /> Date Service Completed (if already completed): SERVILE CODE: t--2- P I E: �2 (,, <br /> Fee Amount:* 5:�-5 '--t; Amount Paid 02�, ego Payment Date 3 wO <br /> Payment Type Invoice# Check# — Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />