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I <br />SAN JOAQAOUNTY ENVIRONMENTAL HEALTIOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />D F <br />3 6- c- 2, <br />n' <br />�E^1.E1` RECEIVED V Ep <br />S Koo S 9 0 '5� <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />JUN 2 4 2008 <br />FACILITY NAME , <br />SITE ADDRESS <br />xJ, C kz U K� !,j`J <br />/ Q 0 1 <br />f•� <br />5LC-2 v6 <br />GLV Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />EMPLOYEE #: % Z <br />7, . <br />3 Lf Lft�h � 0 Street Number <br />DATE: Z,:� 0 <br />Street Name <br />CITY Q -U ►� STATE ZIP IJ �..�J <br />PHONE #1 ExT. <br />-'8-706 <br />APN # <br />vcF 3 — M — L3 <br />LAND USE APPLICATION # <br />PHONE#2 ExT. <br />( ) <br />BOS DISTRICTT7LOCATION <br />CODE <br />7_1 <br />CONTRACTOR / SERVICE REQUESTOR n <br />REQUESTOR <br />CHECK If BILLING ADDR S <br />BUSINESS NAME <br />COMMENTS: <br />PHONE # ExT. <br />(7) 7 ^ ''.S.S Z "2 <br />HOME or MAILING ADDRESSFAX <br />32 2 Y 9,:f ZXL,)14L ,�`(,(/I <br />n' <br />�E^1.E1` RECEIVED V Ep <br /># <br />(7b7)5y,5 -6,51 S <br />CITY 4/1-/4 /; � <br />STATE ZIP QS �v <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: DATE: nn( <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT !� Cj� <br />IfAPPLiCANT 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: <br />COMMENTS: <br />n' <br />�E^1.E1` RECEIVED V Ep <br />JUN 2 4 2008 <br />SAN JOAQUIN <br />ENVI COUNTY <br />ACCEPTED BY: <br />0 ` V l Lp <br />EMPLOYEE #: L; <br />ATLDEPO�# 6 ``- <br />ASSIGNED TO: <br />c!A Ct-T— <br />EMPLOYEE #: % Z <br />DATE: Z,:� 0 <br />Date Service Completed (if already completed): <br />SERwCE CODE: / <br />P / E:� �} <br />Fee Amount <br />Z�ci , t?Zs <br />Amount Paid �' �-- <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # �S� <br />eceive By" <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />