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SAN JOAQI COUNTY ENVIRONMENTAL HEALOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> knes5 evv�e� 71111[13 00 La <br /> OWNER/OPERATOR <br /> 'Y\ - Sha e �e a1 t'K C1 V 10 5 CHECK 11 BILLING ADDRESS 13 <br /> FAcILm NAME �� , S h0. e, �e,,o 1-V\ CI u b S <br /> SITE ADDRESS I905 E Yo 5e rr ).+e. Mar\4eCa '7533{, <br /> Slreet Number Direction � I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> (?01) 6Z3 - of-7y <br /> PHONE R EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORQ <br /> l fJw Cus-tOM -T00 <br /> LC INC yh(e� j�e„^ey- CHECK If BILLING ADDRESS <br /> BUSINESS NAME l/ C 7 y l� 1/"`•^ [•/„PHONE# E.T: <br /> iZOw CuSzora oo� , TNC gal 53-? - 6500 <br /> HOME or MAILING ADDRESS FAX# <br /> 0O cLith 40 me rd Z <br /> ( p9) 53-1- <br /> /, 65Q`1 <br /> CITY l.ere.5 STATE Aft ZIP Q S 3 0 <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 tht application and th t e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar STATE an E Llaws. f—A-L APPLICANT'S SIGNATURE DATPROPERTY/BUSINESS OWNER❑ OPE TOR/ ER ❑ OTHERAUTHOWzEDAGEM <br /> If APPLICANT is not LING PARTS: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 environmental1site 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: �� NT PAYME <br /> COMMENTS: <br /> JUN 9 2011 <br /> SAN JOAOUIN COUNT/ <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: / <br /> ASSIGNED TO: EMPLOYEE M v DATE: <br /> Date Service Completed (ff already completed): SERVICE CODE: fj. OIE: <br /> Fee Amount: Amount Paid t';,qLf- 0Payment Date <br /> Payment Type ■ Invoice# APO <br /> Check# ZS� Received By:/ i <br /> EHD4E-021/1 � �1 SR FORM(Golden Rod) <br /> REVISED 1171772003 I9.I <br />