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SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> I <br /> siness oFACILITY ID # SERVICE REQUEST # <br /> pensing station II OPERATOR CHECK H BILLING ADORESam AliE A&A Gas and Food III Wool MERESS E Yosemite Ave Manteca c tz ostreelNumber Direction Street Namer MAILING ADDRESS (if Different from Site Address) SlreotNumber STATE 21P JON# 1 Ext. APN # LAND USE APPLICATION # <br /> CTyDF ENT�q�NTY <br /> IIJ( 510 ) 396 5560 RTMENT <br /> PHONE #2 EXT. SOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REQUESTOR Emily Crain CHECK if BILLING ADDRESSO <br /> BUSINESS NAMEPHONE# ' <br /> BZ Maintenance 916 371 -2380 <br /> HOME or MAILING ADDRESS FAX # <br /> PO Box 933 ( 916 ) 371 -2540 <br /> CITY West Sacramento STATE CA Z1P <br /> BILLING ACKNOWLEDGEMENT: 1 , 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 or <br /> activity will be billed to me or my business as identified on this form . <br /> I also certify that f have prepared this application and that the wick to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL IaWS <br /> APPLICANT'S SIGNATURE* DATE: rl L � ; <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER E3 OTHER AUTHORIZED AGENT <br /> If APPLICANT IS not the BILLING PARTY, proof of authorization to sign Is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the sante time it IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 44 aee-�4Mf I s--T-es#�a -Bounty . C/( <br /> COMMENTS: <br /> ACCEPTED BY : EMPLOYEE M. DAT f <br /> ASSIGNED TO: EMPLOYEE #: DATE: <br /> Date Service Completed ( if already campieteo 5ERVICECODE: lqk I PIE: % <br /> Fea Amount: ` fJCJ Amount Pal O Payment bate q <br /> Payment T <br /> y <br /> p <br /> eInvoice # Check # 3 U Rece6ed 13y : <br /> EHD 48-02.025 SR FORM (Golden Rod) <br /> 07/17/0& <br /> II , <br />