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SAN JOAQUIN COTY ENVIRONMENTAL HEALTH DEI MENT ry <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A-5 STA rc Ul 3 11/Z_ <br /> OWNER/OPERATOR <br /> ` S CHECK If BILLING ADDRESS® <br /> Cbv1-a to <br /> FACILITY NAME V1b <br /> SITE ADDRESS a:7011 (P <br /> 14(",C a q 434 q <br /> Street Number I 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# LAND USE APPLICATION# <br /> .) . q q 3 .- 1,73-31 --C-7 <br /> PHONE#2 EXT. <br /> ( ) BOS DISTRICT � LOC�4TION CODE <br /> CONTRACTOR / SERVICE REQUESTOR J <br /> REQUESTOR <br /> kCHECK if BILLING ADDRESS M <br /> 0•- �.,L�.Vtti4. <br /> BUSINESS NAMEPHO E# E,* . <br /> SEcrvZc ata- tW* -ewes a- o ,Z13 -(�© y <br /> HOME or MAILING AgDg,ESS FAX <br /> to �S �vl AuR, '13 b P4 <br /> CITY <br /> LL 1aC „ STATE r/1 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 <br /> or 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: . 14,0 460 <br /> 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CL3wb16-()'C-e- 6+(tkV0 <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 itis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: y Sye--C �.( -o _'- r. U -S%(A,t,� ,`.`j�2 ( -7- <br /> COMMENTS: Cel COMMENTS:. WC 1�WV& �K�GTIL�IQr�A YV�I sl( Ep <br /> .SUN 2 2007` <br /> couNN <br /> tJ JOAQuiV14fPL <br /> ACCEPTED BY: v / �; � - EMPLOYEE#: /I / DATE: 2 )-T)A p ARTMEw <br /> ASSIGNED TO: d1 �� EMPLOYEE#: 4�G� 5-/ DATE: <br /> Date Service CompleTtted (if already completed): SERVICE[CODE: ("G 'V, PIE: <br /> Fee Amount: '�z Amount Paid IL� S ( Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br />