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SAN JOAQUIN&NTY ENVIRONMENTAL HEALTH I0ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RPQ ST# <br /> F14 a5D <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> I C ArGit, o ►M t ►a c,v I--z- <br /> FACILITY <br /> FACILITY NAME <br /> SITEAD/DRESS F— <br /> Z l Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S i VA P-- Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (4 3 �j ��c�0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 CµA,e,L W A ( '-0 ( <br /> Y 1`'` IL-T-0 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> (�A L�Ot-( GrCGtt'i2c�<, , c _ Crib 3 <br /> HOME or MAILING ADDRESS FAX# <br /> P. o [3oX t' oz � ( St6 ) 3:�3- 11} L <br /> CITY A-{ rL-Ar-E✓t� STATE CA, ZIP 9 576 Ct <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 F DERAL laws. <br /> 4 <br /> APPLICANT'S SIGNATURE: AtAl- DATE: Fr 1'q 0 <br /> PROPERTY/BUSINESS OWNER❑ OP BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Eff C O V-T-R A-� <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. <br /> TYPE OF SERVICE REQUESTED: p( /k1.fl �Z r--v S P C-C-TfO'F <br /> COMMENTS: RECEIVED <br /> AUG 14 2006 <br /> SAN JOAQUIN OOURTy <br /> ENVIRONMEN <br /> ACCEPTED BY: EMPLOYEE <br /> ASSIGNED TO: 1-0 V A A t4 C\ EMPLOYEE#: l 't ` DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P I E: <br /> Fee Amount: Amount Paida �- .BD Payment Date <br /> Payment Type I Invoice# Check# Receiv d By: <br /> EHD 48-02-025 l -`0 O SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />