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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �e S�04I&J �1rC�i09 '13 .S2Oo-f4 ��- <br /> OJIVNER/OPE TO�. n _ ) I IrQ� 9/ <br /> Tu 7 <br /> L_ Jf CHECK H BILLING ADDRES <br /> FACT ME rirel/ Rl 1 -q q/ <br /> $READDRESS e 35 1 0mbw - /ral',V <br /> O Straat Number Dhe0on tree[Nama cl, <br /> 7 ZI a <br /> HOME or MAILING ADDRESS (If Different from Sib Address) r)i1 --G0 v 6 J <br /> StrM Number 7 W- <br /> Simi Name <br /> Crrr <br /> cMT zip963 <br /> �T• APN# LAND USE APPLICATION# <br /> ►�3i- oa <br /> PHOME#2 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ),p <br /> CHECK NBIWNG ADDRESS <br /> BUSINESS NAME ri /' I A D / n�l^ ,. - P ^ 4`C L C. ./j�J oV 75p Ev. <br /> HOME or MAILING ADDRESS nFer#_ <br /> CITY ✓ STATFeA LP 7l/ <br /> C. /(P <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: DATE: \b S 1 0 1) <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> /fAPPL7CANT is not the B/LUNG PAR7T 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: L- <br /> CDMMENmou <br /> +- PAYMENT <br /> RECEIVED <br /> OCT D 6 2005 <br /> L)IN COUNT' <br /> ACCEPTED BY: dL t V r/ MI <br /> UPA Ipff}T-/ DATE: (0 OS <br /> ASSIGNED TO: �! EMPLOYEE -753 DATE: C) <br /> Date Service Completed (ffalready completed : SERhcECODE: b3 PIE: !, _ <br /> Fee Amount: �-7 c/ uL) I-S < ount Paid �Check <br /> Payment DateOPayment Type invoice# <br /> Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br /> r <br />