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SAN JOAQUIP''"OUNTY ENVIRONMENTAL HEALTP T)EPARTMENT <br /> SERVICE REQUEST <br /> Ty�p/e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> K f/ EM/ GPRO �!�► ��VV �534/(� <br /> OWNER/OPERATOR M1 <br /> k1' .� CHECK If BILLING ADDRESS <br /> FACILfrY NAME <br /> LAS PA S SSI-A7ZF5SuS �r o.J <br /> SITE ADDRRES ��yy��, Sf,4rFA11W4Y"E.(Jr Firoon/rAyE STv c-/cion/ qsz/z <br /> /09� IL49 /t/StreetNumber Direction Street Name city Zip Code <br /> HOME orf AILING ADDRESS (If Different from Site_A/ddress) <br /> 7 j ✓ 7-ON I RE IvE Street Number Street Name <br /> CITY STATE ZIP <br /> -17-'Veyf5w rA 9 2 t <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (20f) 1O -070 -O PA - S-4,916-a <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ON Cf,�FSn/E CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> ('965AI,Ev Cv1VSu6T/1V6 - 03 <br /> HOME or MAILING ADDRESS FAX# <br /> P O . B ( 1 <br /> CITY STATE ZIP 53 <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 projector <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this appkation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, glkE and F• aws. <br /> APPLICANT'S SIGNATURE: (/(yJ2, DATE: /— 2 O O to <br /> PROPERTY t BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of 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: 1CXPJ5D1 re-b N/T 8 uROW~ <br /> COMMENTS: /x/6 XDVo(*RECEIVE D <br /> t�,�c� �° JAN 2 0 2006 <br /> RUSH 1611r RUSH <br /> / S/W� COUNTY <br /> J NVI ENTAL <br /> ACCEPTED BY: V L I L�1 3 Z DATE: 7-6 D <br /> ASSIGNED TO: 'FS t_ p•TZJ EMPLOYEE#: DATE: / O <br /> Date Service Completed (if already ompleted): SERVICE CODE: 47� I E: 24.o2- <br /> I <br /> Fee Amount •7 c��•��> Amount Paid - 9 o •S V Payment Date <br /> Payment Type ,/ Invoice# Check# Recei ed y: n� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />