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SAN JOAQU"' `BOUNTY ENVII2ONMENTAL HEALTT' DEPARTMENT / <br /> SERVICE REQUEST <br /> Type of Business or Property . PACNdTV4}"tN se SERVICE REQUEST# <br /> AC /CUL u 4 L REI/OEI✓TtAL atcC)C-) r1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Inn . ---nOl T ✓AA/DE/Z IFIFEK <br /> FACILnY NAME q� <br /> SITE ADDRESS lb?*Z.¢ 6-�-sT ,000rtfE 4V61\1kE i SLA 4-0� <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10*2-/ r-AST /—W(SF— <br /> Street Number Sheet Name <br /> CITY STATE ZIP <br /> �54,4�0N 6A9532 <br /> PHONE#1 ; �' APN# LAND USE APPLICATION# <br /> 1�f-V7D-3S 4S/obif6 PA - oS - /98 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DD N 12AE5AIgx <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.' <br /> CG/Es,�/E coal s/� Ti i✓C 6G - 40 3 <br /> HOME or MAILING ADDRESS Fax# <br /> P• Q . d Y ( ) 1068- Zs <br /> Cm U 2 LUUC STATE CA ZIP S 3 8/ <br /> BILLING ACKNOIVLEDGEMENT: 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 Is <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 and—FEpqLAL laws. <br /> APPLICANT'S SIGNATURE: vt DATE: g— 62 <br /> PROPERTY <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT W <br /> If APPLIC.4NT is not the BILLING PARTY proofoj thorization 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 environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE as soon as it is av-ailabqoand at the same time it is <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: So/L rA 1 r 6 <br /> COMMENTS: a .� <br /> �aac. h �� <br /> � iv <br /> APyJ AY <br /> RECEI IY . <br /> AUG 5 2005 <br /> ACCEPTED BY: �,L I �-( rZ+rl SAN JOAOU7NENq MPLOYEE#: �'3 Z / DATE: 7W0--c <br /> ASSIGNED TO: P(u 6-6/NS t1Eil.TH[)EPA EMPLOYEE#: OS <br /> Date Service Completed (if already completed): SERVICE CODE: s2 t 9 LL PIE: <br /> Fee Amount. 14 (h6 1( 2 _-11 372 0 Amount Paid Payment Date <br /> Payment Type Invoice At Check# Received By: . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />