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NKN JOAQUIi" rbUNTY ENVIRONMENTAL HEALTH ')EPARTMENT <br /> r SERVICE REQUEST a . 0 <br /> /WI- - <br /> ness or Property I FACILITY ID# <br /> pSE 4C� <br /> 1/1 G{ K ca,r r 5 1av 1 r_D TV3 <br /> OWNER/ OPERATOR <br /> I CHECK If BILLING ADDRESS <br /> t r r o ra,T IOn <br /> FACILITY NAME <br /> U ( 1 rS r <br /> l LaQr4i� <br /> SSIITEQADDRESS S FoG�+off q�ZO Z <br /> Street Number Direction street game city... zipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) eb <br /> %treet Number ��N r Street Name <br /> CITY 1 A ] e � M STATE QIP <br /> PHONE#t \J j EXT APN# LAND USE APPLICATION# <br /> ' (9000 9i t -g36 K �� 3 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t y CHECK 3f BILLING ADDRESSD <br /> F-nUiroll Mer,:! ern 4ei C n raoG In T-/7G <br /> ' $USINESS NAME PHONE# EXT <br /> ! Par IC CGrrOr( V!i lyl 667-230 <br /> HOME or MAILING ADDRESS FAx# <br /> CA (7/11 ) <br /> CITY STATE ZIP ,"2 D r <br /> BILLING ACKNOWLEDGEMENT I, the undersigned property or business o%Nner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL fH 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 certity that I have prepared this application and that the Nrork to be perfoimed will be done in accordance with all SAN JOAQUIN <br /> COUNTY O,durance Codes,Standar ds, STATE and FEDE 1 <br /> APPLICANT'S SIGNATURE DATE <br /> PROPr-R"rVIBUSINESS OWNER❑ OPERATOAGER ❑ OTHER AUTHORIZED AGENT KI <br /> If APPLICANT is not the Bu LING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION %Vhen applicable, I, the orvner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechrucal data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPArzTMENT 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 0-57- JQ- m v T do <br /> COMMENTS RECEIVED <br /> DEC 12 2003 <br /> x E SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED By VDN � EMPLOYEE# S Q DATE <br /> ASSIGNED TO EMPLOYEE# 3 S V DATE <br /> Date Service Completed (if already completed) SERVICE CODE o3 i P!E 2� <br /> Fee Amount (,� �� �Q Amount Paid C-t q J Payment Date j r1Irg <br /> Payment Type Invoice# Check# l Received By <br /> ' EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />