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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> SERVICE REQUEST PA 011050 J <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P'S a- f 4 v LLE21� <br /> OWNER I OPERATOR / <br /> Z ` r .L; CHECK If BILLING ADDRESSff <br /> FACIurY NAME �t <br /> SITDR��EUeeum` t � F /1/4Gt1�a <br /> HOME Or MAILING ADDRESS (if <br /> (If Different from Site Address) <br /> /� 4-V 0 Street Number <br /> CITY SI 6d4' S�64 `eLw/ a STATE, LP /JO <br /> PRIQ L APN# LAND USE APPLICATON# ��GG <br /> rYJVC`Y) I 118-020-070-000 <br /> (HQt1op <br /> E#2(Y/) 7 / 37' 6 / 9 / En. BOS DISTRICT LOCATION CODE <br /> 6 CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PETER WOO CHECK If BILLING ADDRESS® <br /> BUSINESS NAME TW DESIGNERS PHONE# E". <br /> 1 - <br /> HOME DrMAILING ADDRESS 39210 STATE ST., #119 FA"# <br /> CITY FREMONT STATE CA ZIP 94538 <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 <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 tha th@ work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE td FED>" laws. <br /> APPLICANT'S SIGNATURE: �r � DATE: <br /> PROPERTY/BUSINESS OWNER❑ igEM R/MANAGER G OTHER AUTHORIZED AGENT <br /> /fAPPLICrNT is not the RfliIWG PARTY proof of authorization to sie r is required Tielc <br /> AUTHORIZATION TO RELEASE INFORMATION: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. .L" <br /> TYPE OF SERVICE REQUESTED: Iv LA r.ILS R <br /> COMMENTS: <br /> .�(RGfi'Dn 2 Stc r�1 SUN FD <br /> Una.a"f sq Af �5 ?0 <br /> O <br /> hFAC>'RONMN COU <br /> W dQ51 n rJ p(I�.00 r Cpm NOfp FNTq N,`Ty <br /> ACCEPTED BY: G,L,�, 'k C- EMPLOYEE DATE: wry <br /> ASSIGNED TO: rt hI '61''" EMPLOYEE#: DATE: &—s- Lit .e <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 0 <br /> Fee Amoun • rOa QD Amount Pai — Payment Date <br /> Payment Type V 1,54— Invoice# Check# /0910 2-40 Received By: <br /> EHD 46-02-025 .SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> Pd by C'C' <br />