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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S0oS3gs4 <br /> OWNER/OPERATOR <br /> Webster Williams CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS E Ei ht Mile Road <br /> 9 Linden 95236 <br /> 17337 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 1477 Street Number Street Name <br /> CITY Linden STATE CA ZIP 95236 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (818 ) 205-7399 065-100-45 <br /> PHONE#T ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Tristan Hartung <br /> BUSINESS NAME PHONE# ExT. <br /> Dillon & Murphy 209 334-6613 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 2180 ( ) <br /> CITY STATE A ZIP 95241 <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 FE RAk I S. <br /> APPLICANT'S SIGNATURE: DATE: - (Z'?�t-1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER6b OTHER AUTHORIZED AGENTV Party Chief <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: rU � <br /> I new �Gots rP z>1 A <br /> SVf t- � Gn SU�Sui�1 � c�on�-�rm jPV•E' <br /> COMMENTS: OV�h <br /> bAN'/OAQ <br /> HSE"VC H/�Ep1wety L <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S a PIE: <br /> Fee Amount: 4 30I Amount Paid b y,— Payment Date —q-1(3[ <br /> Payment Type Invoice# Check# 2 T 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 1 <br />