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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SSE_ RVICE R�fIUFQT-0 I <br /> Actl?icUbluizL KO(r�YJl1(1�CCJ/_( I7 VVOO <br /> OWNER/OPERATOR A1,EvE2 r p Nn/ LLQ <br /> U T� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS �QZ G-� cS-ri4 MPFDE Lppl ySZyu <br /> 1 Street Number Diracfion Stresl Name �1 11/I Ci ZI Cod. <br /> HOME or MAILING ADDRESS pf Different from Site Address) 2 I y l fT i 6 tf W A Y Z2-L( F145-17 <br /> SReal Number Street Nama <br /> CITY s(u�IZ-F am A( STATE 42 zip'7ZN-73 <br /> PHONE#t EAT' APN# LAND USE APPLICATION# <br /> (870) 3L1 �1 - 5562 ©1q- 3No l3 <br /> PHONE yj EXT. BOS DISTRICT LOCATION CODE <br /> IZo91 a - r�130 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REGUESTOR n I� I / CHECK N BILLINGADDRESS .I <br /> BUSINESS NAME K N ` PHONE# EXT. <br /> D11-c � Niu Zo 3 0 <br /> HOME or MAILING ADDRESS FAX# <br /> Ro a too- (uq ) 33 H -c)-7 Z-3 <br /> CITY y U STATE C ZIP ql/7 Li <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 <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> I1 rr`L� 'ZS �UppG <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT la LN�I N r <br /> 1f APPL/CANr is no(the BILLLNG 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 environmentaVsite 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. .r- <br /> TYPE OF SERVICE REQUESTED: �iJ IL�iLFC� Sug 5uop*-ce /Z-� ` PAYMENT <br /> COMMENTS: �(/� 010 �W <br /> K1° t APR 2 5 2006 <br /> ANN COUNTY <br /> {' <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ;::neui <br /> DATE: <br /> ASSIGNED TO: If 0 WA EMPLOYEE#: DATE: 77 <br /> Date Service Completed (if already Completed): SERVICE CODE: P IE: <br /> 07 <br /> Fee Amount: Amount Paid 'b iF D p Payment Date Llij2510 to <br /> Payment Type ✓ Invoice# Check# Py S Received By: ( <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />