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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ASR/L rk1ZAL RES/DENT/a L r� y U (O <br /> OWNER I OPERATOR <br /> // IZ ¢✓�'/ CHECK If BILLING ADDRESS <br /> /0 A(DE <br /> FACILITY NAME VAAIDE F C /` <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 19417- I-aal 5 E A I/E NGfE <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> ES�AGDn/ GA 1753zo <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# PA p"/(�S <br /> ( ) 030 - 64 ao Opo- 35 PA - <br /> PHONE#2 Ezr. BOS DISTRICT / LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 00 <br /> tv CYLJ T` CHECK If BILLING ADDRESS Er <br /> BUSINESS NAME PHONE# En. <br /> CHF-5tP GONSULT/n/C ( ) 660- 140 <br /> HOME or MAILING ADDRESS FAx# <br /> P o • Pox 374 ( ) &� -z <br /> CITY TU 2 L OSTATE CA ZIP S 3&/ <br /> BILLING ACKNONVLEDGEMENT: 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,StandardZfift <br /> TE and F RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12 - 5--0(, <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER OTHER AUTHORIZED AGENT <br /> IfAPPL/CANT is not the BILLING PARTP proof f 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: 541/ZFACE AAtl S!.l BSt!/ZFA�E CO.v ra/rT/NAT/d O /LF✓/Eli/ <br /> COMMENTS: a }aa� � gw �r.rv}/ r „A' RECEIVED <br /> DEC 0 5 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: _ EMPLOYEE#: DATE: f Z <br /> ASSIGNED TO: D,12EMPLOYEE#: 0 DATE: <br /> Date Service Completed (if already completed):-t�v SERVICE CODE: 3/ /�-� P f E: ��0 <br /> Fee Amount: i O Amount Paid Payment Date ., <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD48-02-025 SR FORM.(Golden Rod) <br /> REVISED 11/17/2003 <br />