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SAN JOAQUIN_ COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> SERVICE REQUEST# <br /> Type of Business or Property I°ACILITY ID# <br /> R A 4- - CO/rl�lElZ c[A L 9O V 79 2S <br /> OWNER/ OPERATOR T�A <br /> f7 <br /> R rX eQ 0 VIS n9,5' ✓ 14- s 1CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> CA R V sTo P K <br /> SITE ADDRESS /0000 9As7- 14/6 HW'qy /20 M/1; A /45-.3.7 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) CA s T )1a5'E II rF <br /> Ave- <br /> 0 Street Number Street Name <br /> CITY ,{ � CA STATE �^ ZIP �S3 <br /> �r 1 <br /> PHONE#1 EXT. APN# LAND USE APPLICA # <br /> 10 1 ) if - 3(,0,7 030 - ;-74 <br /> v <br /> PHONE#2 EXT. BOS DISTRICT //� LOCATION CODE <br /> a <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR D0 nl CF 5 'g CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C EStvE Nfr� �4�� <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY a PL-V6k STATECA ZIP q7-?g/ <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 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,Standards, S E a*FIERALws. <br /> APPLICANT'S SIGNATURE: DATE: 3PROPERTY/BUSINESS OWNER❑ OPERATOOTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING 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: i'WA6 C L t3 R G—E CONTAn1iNa rro�/, Po,e ndL t�/ <br /> COMMENTS:'111 f � • " /j,n.,LT���CsI L/> '� ) <br /> -7 � MAR - 9 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: fj1 n9() I '� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , P I E: <br /> Fee Amount: l (� `� Amount Paid 1 (� Payment Date 3 l b V <br /> [Payment Type Invoice# Check# 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />