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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2�. T-� cL L f7-U E.,L- ,3(��'1 <br /> OWNER/OPERATOR <br /> Ac iA A,6,1- CHECK If BILLING ADDRESS <br /> FACILITY NAME �2 L►�Yt 0 i�1 L <br /> SITE ADDRESS E �(t f✓yVl 0 Ni� S T S TO Cly T�� q S'2 O f' <br /> 2 l C1 Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> A,^e- Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> Gogo gqt – 15- —2 Z ug <br /> PHONE#2 Err. BOS DISTRICT LOCATIQN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR W I C O1 A Crz.� . CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> L ^ � T '� 1G <br /> 3-4-3 - <br /> HOME or MAILING ADDRESS ` Q O FAX# <br /> 10 2 (9/6 ) 3 :�Z (0-L <br /> CITY W ISS.- A— (-?- Ar VA 6--r-0/ STATE CA ZIP q S b q / <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 an#that the work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE d F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ID it /o <br /> PROPERTY/BUSINESS OWNER 13OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT R C0*X-T—fz A- rL— <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. (,(-S-F" 12-�—c-1 F <br /> TYPE OF SERVICE REQUESTED: P Cr.-1 TZ FiU L(;iuJ ECENE[D <br /> COMMENTS: OCT 11 <br /> 2007 <br /> FE ►�'"��j SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> EXE 111 HEALTH DEPARTMENT <br /> ACCEPTED BY: G js� /J.- EMPLOYEE#: C)3-ZI DATE: `U �Q- <br /> ASSIGNED TO: E.N l� EMPLOYEE#: (G L1 Z DATE: /D <br /> Date Service Completed of already completed): SERVICE CODE: I`�f PIE: ��Cid <br /> Fee Amount: Amount Paid Z�02�4 67C) Payment Date <br /> Payment Type ! Invoice# Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />