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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of or Property FACILITY ID# RVICE RE T# <br /> c <br /> A ru,e� Esso Tia <br /> PERATOR <br /> IDA <br /> CHECK IfBILLING A S <br /> FA TY NAME <br /> SITE ADDRESSA57— -771-FF,4 Al 44/Vt<- SCS{ LC7N �j��zc� <br /> Street Number Direction Street Name city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Ad ess) 5-j 42 /V` E""f 7-,EA 1/E/ 7- Z <br /> Street Number <br /> Street Name <br /> �I A K ^L� - STATE nX ZIP �S / <br /> PHONE#17 EXT. APN# -(� LAND USE APPLICATI <br /> c ) g 7- g2/ X70 - Soo - ll% PA - os <br /> PHONE#2 EXT. $QS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ;� <br /> Y O AJ /� j IE�. /C CHECK if BILLING ADDRESS� <br /> BUSINESS NAME V C_ 1 1 ��l L PHONE# EXT. <br /> �&8 -14 o <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> 141 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of salve, <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 applipoon and tha work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S and FED WS. <br /> APPLICANT'S SIGNATURE: DATE: (O Z - ac, <br /> PROPERTY/BUSINESS OWNER❑ OPERATO�A�RTY <br /> AGER ❑ Inhoroization <br /> THER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLINGproof of�ato 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: p/G S-u /TA D/L _Q(P E D -rF p RIFV I <br /> COMMENTS: <br /> 081a <br /> (J viavv '��i � C , .11 9��EIVED <br /> C o �, n''�— (, JUN 0 2 2006 <br /> SAN <br /> N�RO UIN COUNTY <br /> HF_ALTN DF MENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: /�� DATE: <br /> e Completed (if already completed): SERVICE C`O'DE: P I E: <br /> Fee y. [I>' Amount Paid 3 Z Payment Date q LI <br /> Payment T ✓ Invoice# Check# aS p Received N(,- <br /> EHD 48-02-025 SR r (Golden Rod) <br /> RFvI.qFn 11n7/9nn-i <br />