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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK N BILLING ADDRESS❑ <br /> �pBE/�/TL�tJDEP-C� -�o+4rJ YUG-AZl <br /> FAca1TY NAME M U!4' �^t�N /c-65S I <br /> SITE ADDRESS 0 <br /> (F> -7 N , ^(l,(J��"C RooD LIN�Gn1 �jSZ <br /> St((r.77ae�✓t Number Direction treat Name C' Z1 ewe <br /> HOME or MAILING ADDRESS (If Different from Site Address) (o Z�/� 1416#P4'Y Z b <br /> Street Numtror Street Name r.� ' a,x <br /> CITY vl N^E I STATE �r,r LP 4 � 03 <br /> PNOIEV 'J N Ex . APN LAND USE`AP/-tP-DCATION• / � <br /> (2�1 �3 - (-7 (b5-c�(oo-12 13 —14 - -no/PHONIER <br /> no/ S�fJ <br /> PHOr1E#Z Ear. BOS DISTRACT LgcAn0N co <br /> rT <br /> 1' 1 <br /> o _ 76 ") C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQuESTOR CHECK If BILLING ADDRESS <br /> # Exr" <br /> BUSINESS NAME PHONE D(1 I ..� Moe-to4y 3 -(� l3 <br /> HOME or MAILING ADDRESSFAX# <br /> P o . `I3ox 2120 ( - , 3 -o-7Z:5 <br /> CITY (-OD I STATE CZf <br /> A ZIP `:3fr ' <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY ordinance Codes,Standards,STATE an L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER OTHERAUTHORIZED AGENT <br /> IJAPPLICANT is not the BILL/NG 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: f.L A C 94�4 C E Cc Air - UAYNAENT <br /> COMMENTS:Hpv p6 lilz� Cz wvw RECEIVED <br /> ,(' SO,,,..� OCT 12 2005 <br /> SAENVIO <br /> RONMENTAL <br /> ACCEPTED BY: �i[.-tV�( (� EMPLOYEE#: 032-( DATE: /0 Ar22r--.== <br /> ASSIGNED TO: .�S C O EMPLOYEE <br /> Date Service Completed (N already completed): SERVICE CODE: 3 IS PIE: 2-6.C' <br /> Fee Amount: 71 E G,_CE ) Amount Paid O Payment Date 1 p 12 os <br /> Payment Type S Invoice# Check#Jf b;a S ,. p 9 3.60 Received By: <br /> EHD 48-02-025 _ vJ SR FORM(Golden Rod) <br /> REVISED 11/172003 <br /> e <br />