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SAN JOAQUI` ` 0UNTY ENVIRONMENTAL HEALT' 7F,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A uG u L - eEStC)En/ /At- �e6o'61 1;2/ <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> M12 - /-outs ac'AIE <br /> FACILITY NAME <br /> SITEADDRESS `,G� TOKAOL OA/Y AO- LNJl7 Gf j Z J <br /> Street Number Direction St re t Name� City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /-20�7/ 51gS7- L 1l/,F- to K iQU4 1, <br /> Street Number Street Name <br /> CITY 40c) STATE ZIP <br /> � c�4 q�Z�v <br /> PHONE#1 EXT' APN# LAND USE LICA ON# <br /> (2vq) --2-03 - 1391 4& 3 _ 00 -- X26) <br /> PHONE#Z EXT. BOS DISTRICTS ( LOCATION-CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �> <br /> Ulm t�f�ESN E CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> < � X ( ) /�6Q-ZSrjB <br /> CITY( LD STATE ^ ZIP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S E and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING 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 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: SGl/Zf�GEAWO f B eF F 'TtliWi,- Ar10A1 REPOA?— eFV1F- t/ <br /> COMMENTS: C-) �i�f (3 PAYMENT <br /> rl/�Evla,-j--, RECEIVED <br /> JUL 6 2007 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: v(,_� EMPLOYEE#: D 'J,U0iH DEPAR 7/6107 <br /> ASSIGNED TO: F-96-0 'rD EMPLOYEE#: DATE: —7 Q-7 <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: <br /> Fee Amount: S•U �J Amount Paid �O< Payment Date �— <br /> Payment Type ` Invoice# Check# a7�� Received By: e-7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />