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SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4� <br /> SERVICE REQUEST <br /> Type tx; Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci 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 # LAND USE APPLICATION# <br /> i <br /> ( ) <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> KUYKENDALL SIMAS, LLP <br /> BUSINESS NAME PHONE# Err. <br /> (916 ) 930-1900 <br /> HOME or MAILING ADDRESS FAX# <br /> 1201 K STREET, SUITE 1950 ( ) <br /> CITY STATE ZIP <br /> SACRAMENTO CA 95814 <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,STATE and FEDERAL 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. N� <br /> TYPE OF SERVICE REQUESTED: SUBPOENA CV-023978—APPEARANCE ON 11128105 P GE�v <br /> COMMENTS: cl `Lo <br /> DSD d+ �ovN� <br /> g�N app.�NMEN�M N'C <br /> LIkAp�ppS� <br /> H <br /> ACCEPTED BY: MARGARET LAGORIO EMPLOYEE#: 0942 DATE: 1212105 <br /> ASSIGNED TO: JEFFREY WONG EMPLOYEE#: 9488 DATE:: 1212105 <br /> Date Service Completed (if already completed): SERVICE CODE: 515 P l E: 4897 <br /> Fee Amount: $150.00 Amount Paid $150.00 Payment Date 12/2/05 <br /> Payment Type CHECK Invoice# Check# 13739 Received By: VD <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />