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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH IWRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 16 <br /> FACILITY ID# bL f 7_S SERVICE REQUEST# <br /> SOLw9 <br /> D 5T,- --002-4UJ �7 <br /> OWNER/OPERATOR <br /> lH//J EP E f D CHECK If BILLING ADDRESS <br /> FACIuTY NAME TRAtc ReCO Vie 4 F/�L-%)`y <br /> SITE ADDRESS 3 O ilt-O 3 J - T y r/¢e4* rT'v'Q px rE O y ?--5 3 T 110 <br /> Street Number I Direction Street Name C' Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SS" O V Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (sog) 83S -0601 ;253._ 1 .3c= NpF <br /> PHONE#ZT BOS DISTRICT LOCATION CODE <br /> ( ) 932 - 2-355 S 5 i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CV4N <br /> ,r� CHECK if BILLING ADDRESS El <br /> BUSINESS NAME �/fjlrl7s- PHONE# Exr <br /> HOME or MAIuNG ADDRESS t� FAX#P T <br /> /$ZZ ZI sr 577,L=i=-fi ( 9116) 3X.39 -/2/6 <br /> CITY s4(olo17111 EN1-D STATE Clq ZIP 738'1 Ll- <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: A& � <br /> � Laze?fr�- DATE: 5f/2�0 z <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑—�p�C�i—. <br /> If APPLICANT is not the BILL/NG 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. PAY M E 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: MAY 0 8 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: U L V,ZC 1EMPLOYEE#: Zl DATE: G <br /> ASSIGNED TO: 4 G -E<_� EMPLOYEE#: T� DATE: G <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: st Oma- <br /> Fee Amount: `f7 S C- Amount Paid S. C9, Payment Date tJ 1J-7 <br /> Payment Type �� Invoice# Check# s S Received By: lV ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> I <br />