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JANJOAQUIN COUNTYENVIRONMENTALriEALTH UIEPARI'MEN'Y <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# C SERVICE REQUEST# <br /> q ICU L UR l- RE510ENTlA S �Q�O ✓ <br /> OWNER I OPERATOR <br /> MR . mo7VT VAIVDER BEEK CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1,942.4 q jo4i& EAST LOUISE 4l/E. ,ESCALl7N g5-3Z-0 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ig4z I r,-44T G-o"r 5E <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> ESCALUAU/ CA ?-S-?Z0 <br /> PHONE#1 Err' APN# f-L(4*0 C&p*0 LAND USE APPLICATION# <br /> (2v9) e3d- A 205-070- 35 $ PA - 07- I t'k75 <br /> PHONE#2 Ext BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Do/k/ /�L�� CHECK If BILLING ADDRESS UJ <br /> BUSINESS NAME C•r/ / PHONE If Ems' <br /> CRE5N€I VCoNIu�TiNl HOME or or MAILING ADDRESS FAX# <br /> CITY // JZ STATE ZIP �Y8/ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/oI 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 tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FE L laws. <br /> APPLICANT'S SIGNATURE: DATES�:(( 51- 6F7 <br /> / <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 91 <br /> If APPLICANT is not the BILLING PAR Tr proof of a 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 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: 'OIL fJefTAL%/L /T STr.(D /// EVIEVI r , RF_CEIVED <br /> COMMENTS: /D �1 CA <br /> 1rjd�.e�rJ 70��/' <br /> 7 r` MAY 0 9 2007 <br /> Q- SAN JOAOUIN COUNTY <br /> HATHDNMENTAL <br /> EPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE O DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: y- PI E: O <br /> Fee Amount: t O �' Amount Paid 1� j St; Payment Date - Y IC 7 <br /> Payment Type �. Invoice# Check# Received By: -JG'_. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />