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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �,. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � RES/DENGF ��24D¢� 2�' I <br /> OWNER/ OPERATOR <br /> til BILLING ADDRESS <br /> R . TON DUTRA r7o en <br /> FACILITY NAME •" _ <br /> SITEADDRESS r)` / INN//V g,9A b M,4A17-,EeA of 6337 <br /> a 3 Y/O Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# APPLICATION#50 —7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION COD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> O CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 6AJ5-w�V CaAlfut-Alli 6G8-/4o� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY //� La STATE CA ZIP IT <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 appli ion and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST. and FED Laws. <br /> APPLICANT'S SIGNATURE: DATE: /0 U <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ THER AUTHORIZED AGENV1q <br /> If APPLICANT is not the BILLING PAR TY,proof of aut 6 ation 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: SOIL fu I rA 8/L/ I TII= <br /> COMMENTS: �(1/�j/ to 9 a PAYME <br /> RECEIVED <br /> P RUSHT 1 0 2005 <br /> SAN JOALIUIN COUNTY <br /> VIRONMENTAL <br /> ACCEPTED BY: �Lt VE EmD 3 DATE: <br /> of/',,o <br /> ASSIGNED TO: ' f-�LL 6- - AIS EMPLOYEE#: �(� DATE: 0 <br /> Date Service Completed (if already completed): SERVICE CODE: 572-2- yZ P I E:-ZL•O/ <br /> Fee Amount--4L �-'-�;72-10 1 Amount Paid 3-7 ; Payment Date Ofl O <br /> Payment Type Invoice# Check# �4 b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />