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RL�� u D PAYMENT <br /> RECEIVED <br /> FEB 2 4 2006 <br /> ENVIRONMENT HEALTH <br /> PEUIMSERMES SAEN�ROONIN COUP <br /> NTY <br /> SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH EPARTMENT HE NVI DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> [��ERVICI/� REQUEST g <br /> 04 <br /> OWNER/OPERATOR <br /> pl-k2—C--C�' CHECK if BILLING ADDRESS <br /> ff <br /> FACILm NAME <br /> SITE ADIIRESS 3 z <br /> tNuor <br /> 9 Z <br /> HOME or MAILMIO ADDRESS (If Dfffarent from Site Address) <br /> ip Cocis <br /> Sheat ber Name <br /> CITY STATE Zip <br /> PHONE#1 ExT• APN S I Arto USE APPLlcATION# <br /> ( l <br /> FPRNioNEIt2 Ex*. <br /> SOS DISTRICT LOCATION CODIE7 <br /> 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Z=� Ott t_--Y CHECK if <br /> BUSINESS NAME 1 0 En <br /> z-7 <br /> HOME Or MmuNa ADORE$$ FAxt) <br /> ( ) <br /> CITY STATE <br /> —I 7JP <br /> BILLING ACKNAWL1MQ2d rM; 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 ny 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,STA laws_ <br /> APPLICANT'S SIGNATURE. DATE: 'Z- <br /> PROPESTY/BUSINESSOwNE:RO OPERA <br /> OTHER AUTHORIZED AGENT 'L�t=r-rT- <br /> lfAPPLICAVT is not the 81LLINC P.11eTY prao f 0f anthvrtw on to skm is required Title <br /> AiJTHORiZATIUN TO REi EASE 1NFOR yAL—_ When applicable,1, 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: L•�T-1 Osv2a� i t C`� jJ E dl .i F EN <br /> CattIENrS: ED <br /> FEB 2 4 2006 <br /> SAN <br /> HE NORpNMENTq(, <br /> UIN COUNTY <br /> ACCEPfEO BY: �✓ r ` =i : EMPLOYEE#: f� ? DATE; -7 r T <br /> ASSIGNED TO: t' �):) E mmoyEE#: td DATE: 7 l v <br /> Date Service Completed of already completed); SERWA CODE: cl h' P i E: <br /> Fee Amount:I .1�y •4, Amount Paid Ot 60 1 Payment Date a 2`E b b <br /> Payment Type involca# Check 0 L 5 Z Received By: <br /> EHD 48-02-025 <br /> REVISED 11117f1003 SR FORM(Golden Rod) <br /> ST 'd L296t,0629S H0311406HUZ) WU60 :6 9002 TZ qa3 <br />