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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CO/J� McI?C/Q Z <br /> OWNER/ OP�ERAGTxOR / /� <br /> /�1 ,x rL—c,4 .4 �`,E- �'.¢r�7PER ZSIC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> MAM7-,---CA A 5rORA F R/ARK <br /> SITE ADDRESS logo p eA S r /z//�If/r✓A/Y /Z O I�'�ANrz=c,4 953 3(0 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7/ SOGI rf/ $EC� �4 fZOA p <br /> Street Number Street Name <br /> CITY 0, / STATE CZIP <br /> ao <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zvi ) 333 - /0/0 ZZB -o30 -Z4 PA - 06 /So <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> O t'i CHECK If BILLING ADDRESS <br /> BUSINESS NAME ('!7 /vG PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> F- 0 - 50k 371c )663- Ls <br /> CITYMLD $TATE ZIP -5 <br /> BILLING AC\KNOWLLEEDGEMENT: 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 thisap ation and th t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, E and F laws. <br /> APPLICANT'S SIGNATURE: Z20� DATE: Z Z aG <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR1%IANAGER El /( <br /> THER AUTHORIZED AGENT 19/ <br /> If APPLICANT is not the BILLING PARTY 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:8/ At7 1�SEN t <br /> COMMENTS: <br /> 111 µet�f j 'DEC 2 S 2006 <br /> COUNTY <br /> l� SAN OAO <br /> Y'1 EN�H pEPAR M NT <br /> ACCEPTED BY: EMPLOYEE#: o v l DATE: �7.j fr' C06 <br /> ASSIGNED TO: EMPLOYEE#: y� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �"� PIE: -Z& •D <br /> Fee Amount: •S/T� Amount Paid q t Payment Date a2 2 g <br /> Payment Type Invoice# Check# 43 Received By: g (�, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />