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SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTP '1EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P,QODt,(CE STAIN 1A61zle,14tT-u2Ae- 5200, 56ff 3Z <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> A ORFW 5,EPN0S eWAIER- /YJ/Z. A/EGTO/z :�Ae- C0 OP- <br /> FACILITY NAME <br /> IlAeaas (32OT4E25 P2C7DG(CF <br /> SITE ADDRESS /'q95� FAST /Z D IYI<1/�/TEC/{ 9�X310 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S O(.(TI-/ rn r Cl-"EL L lZa. <br /> 3 Street Number <br /> Street Name <br /> CIN STATE C,4 ZIP els <br /> i�"1A NT�eA 3 3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> cloy) y�9 -/9z3 2zg-03o -25; PA -o0 - o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 00nI C14E51rCCHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C e5t4E G'ONSu l—rI1 2 ( ) wG9 14 0,3 <br /> HOME or MAILING ADDRESS FAX# <br /> 0 , Cox 37'qz'r- <br /> e'-K <br /> G(C STATE y/ zip 17-5391 <br /> BILLING ACKNOWLEDGEMENT: 1, 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>t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, SE and F I.laws. <br /> APPLICANT'S SIGNATURE: DATE: <D - 1-7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY proof o 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: ITi2A ,F GOA DiNy STUD fv/L 5U t r4,3)1/T 15r-(,4,D (-I <br /> COMMENTS: CDAYMETTT <br /> ee.'Z� �l � ' ;DECEIVED <br /> JUN 0 4 2007 <br /> i <br /> SANppJ�TF-N�IRONMEt`IT N <br /> CEPTED BY: EMPLOYEE#: -U <br /> iIGNED TO: EMPLOYEE#: Ot_/f� DATE: <br /> Service Completed (if already completed): SERVICE CODE: [[ �� P 1 E: <br /> 4mount: CSS Amount Paid WT�;' L Payment Date 0 <br /> ent Type Invoice# Check# Received By: 2 <br /> -02-025 SR FORM(Golden Rod) <br /> 0 11/17/2003 <br />