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SAN JQA I VIRONMENTAL HEALTH i,r:PAIRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ocT _ 1 2007 FACILITY ID# SERVICE REQUEST# <br /> S444-1c-p— AL 3IO&S S�ofl S 2 l -2�S <br /> OWNER/OPERATOR p�Rj�j,'T"SERVICES <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME ,V n 0-3 1 b6, <br /> 6 r <br /> SITE ADDRESS U cX/ L+L U t, q,s3 3� �1-Z4>Q-�-t_ L. I. a <br /> ---Street Number I Street Name Cit Zi 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 /> PHONE#2 EXT. BOS DISTRICT? LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> S /cl�C4 O �Z_ CHECK if BILLING ADDRESS D <br /> BUSINESS NAME PHONE# EXT. <br /> ` ZG4 3�S— l"2�(0 <br /> HOME Or MAILING ADPRESS FAX# <br /> 62 171 �. Lal✓ `C- e 49 r-A ( 21-A) 3 b S--(S 3 <br /> CITY <br /> Lc) {its STATE�� Zip IS •L Lt O <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or pro'ject specific ENVIRONMENTAL. HEALTH DI PAR'I-MEN'I'hourly ch rges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 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 C'oc/es,SYancdards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: pAI'E: pp/f <br /> 'PROPE,141.0 BifSINESS OWNER El OPERATOR i MANAGE.R ❑ OTIIFRA n'llIOR[ZEDAGENT UT 611.4- CF---- -- <br /> if PPLICntvr is not the l3/lvvo PART) proof of authorization to sign is required Otte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the propertN located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/gr environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONNIFN FAL HI:AI.'I'I I DI:PARTivlliN'I'as soon as it is available and at the same time it Is <br /> provided to me or my representative. <br /> 1173A-Uh Ar-.IT <br /> TYPE OF SERVICE REQUESTED: C.�ST,Q�- a F— l — RECEIVED <br /> COMMENTS: <br /> OCT J 2007 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �#:EMPLOYEE I DATE: � ,0` r ( ' <br /> 3 Z l <br /> ASSIGNED TO: Al ' f VL{— EMPLOYEE#: ,�Sp'z DATE: frV O ^7 <br /> Date Service Completed (if already completed): SERVICE CODE: ( p i E: 3 8 <br /> Fee Amount: Amount Paid q)-A0U Payment Date � ,i, I <br /> Payment Type / Invoice# Check# \b 5/� Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />