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SAN JOAQUiPUNPY ENVIRONMENTAL HEALT4PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property +01 FACILITY ID# SERVICE REQUESTC s C.) �s2f�S1 ��37aU kem'5( <br /> OWNER/OPERATOR � 1 ^ �t <br /> 'n der, J J CHECK I}BIWNG ADDRESS® <br /> FACIuTv NAME <br /> SITE ADDRESS <br /> Street Number strev city Zip Code <br /> HOME or MAIUNG ADDRESS (If Different from Site Address) _ <br /> Street Number Street Name <br /> CITY STATE _—_ ZIP <br /> PHONE#1 E"r• APN# LAND USE APPLICATION# <br /> (2(fl) "4b5 - 3gg0 - 14 S6ko/6 <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTORLobea QPkJ1LL <br /> CHECK if BILLING ADDRESS El <br /> �\1- <br /> PHONE# EtT. <br /> BUSINESS NAME e-6 tQb(e "eU S"e r✓I Ccs '"�JCC• P O asao <br /> HOME Or MAILING ADDRESSI 1_r (X <br /> 5 o ) &4S_ 5 3 <br /> 13 r 1 <br /> Crry STATEt G1 LP R53(01 <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,Standar TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C1 C/� � Y^L1r11eVV\) DATE: 12 //q1 08 <br /> PROPERTY/BUstNEss OWNER❑ OPERATOR/MANAGER 13T 7OTHER AUTHORIZED AGEN7 (,( <br /> If APPL/CANT is not the Btu/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. <br /> TYPE OF SERVICE <br /> REQUESTED: <br /> O I� � J (IV ,�(� c .Qe- ,y� 'q Y <br /> COMMENTS: 11/rll , I�/I� I I I i Yee.(. 0.QX. ,t 't �{ Jeal — L( / <br /> COIck S�� +c' .Ke.B P ?22008 <br /> ".Ou <br /> NtN�U <br /> H�EpMFMq�Ni1' <br /> ACC BY: EMPLOYEE#: �� DATE <br /> ✓^ a o <br /> ASSIGNED TO: EMPLOYEE#: p--3i DATE: <br /> Date Service Completed ( already completed): SERVICE CODE:/c PIE: <br /> Fee Amount Amount Paid ^ d Payment Date �a <br /> Payment Type �/ Invoice# Check# R ived dyr <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />