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SAN JOAQUINCOUNTYENVIRONMENTALHEALTHVEPAXIMEN1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 21044TKR.4 4- I 7 7 <br /> OWNER/ OPERATOR <br /> I71CHAeI- 4 WC�p 5,�f CHECK If BILLING ADDRESS <br /> FACILITY NAME 1� s5 <br /> -s� <br /> ST-OkrmtrA <br /> SITE ADDRESS 758/ WEST' KILE ,LOhD 7Ho2n/7Dn/ q>GSG <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 /> ('o! 1 ?14 00/- 23o-3 PA -d3 - 025 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �) <br /> POIr CNECK if BILLING ADDRESS <br /> BUSINESS NAME C. R PHONE# EXT' <br /> CNESNCY CONX04 /N G`g- l 0 <br /> HOME or MAILING ADDRESS FAx# <br /> O. 0k 3714 G60-7-S B <br /> CITY TGCRLOCK / <br /> STATE t A ZIP 5 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S' a and FE laws. / <br /> APPLICANT'S SIGNATURE: �/ 1 DATE: T' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED ACENT� <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 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: 6&111I A13!L 6TC! - FxPeDireD <br /> COMMENTS: EC_,cIVED <br /> APR 0 5 <br /> 2007 <br /> S ENVI AQUIN COU <br /> NEAITI D NMENrq NN <br /> ACCEPTED BY: 1, L U t EMPLOYEE#: 0 2 Z( DATE: � S b <br /> ASSIGNED TO: �,(} , e /A- EMPLOYEE#: _5-.2`(� DATE: 4/S'107 <br /> Date Service Completed (if already completed): SERVICE CODE: 6L a 9 av 1 PIE: )_(,. 0 <br /> Fee Amount: a (oj 0 00 "C 1-5= 's I Amount Paid ?b 5_ 0) Payment Date L4 g Gi <br /> Payment Type Invoice# Check# 1b S Received By: `;4Zr <br /> EHD 48-02-025 .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />