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Vr N k0VAYWN UOUNTYENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQ/UEST/# (� <br /> fOrMer S¢cvl 5}al,ph <br /> OWNER/OPERATOR <br /> F-42A SAn v,'A t CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS any Ks <br /> C':t r+wy y FArM,h9�„ 9S23a <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 10&210 E, cope 'Ogcl.-y 2& <br /> Street NumberStreet Name <br /> CITY STATE ZIP <br /> CA <br /> L.,,{Cn <br /> PHONE#1 EXT. APN# <br /> LAND USE APPLICATION# <br /> (coq) Goy gaa,I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C�.r-,S r"\ ,l♦\eT Cat 601 � Ssy � CHECK If BILLING ADDRESS <br /> BUSINESS NAME oo I� ( 1. PHONE III E' . pp <br /> APUPIALJ Geo V1r0n �ti1 JLCI 4 ] ' (WL- ')-V <br /> HOME or MAILING ADDRESS FAx# <br /> 931 Sh, . 04 (a0q) yt.� - PIIS <br /> CITY Cr L,)LL.� STATECAZIP gnats <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 or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this p 'tion <br /> tion and that the work to be performed will be done in accordance with all SAN JOAQU <br /> COUNTY Ordinance Codes,Standar s TE and FEQ§RAL laws. <br /> APPLICANT'S SIGNATURE DATE: -7-23-Of- <br /> PROPERTY/ <br /> 7-23—O(.PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTS <br /> IfAPPL/CANT is not the BILLiNGPARTY 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 JOAQUN 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: OS-T E-eY^Ovn..l PAYMENT <br /> COMMENTS: <br /> APR 2 4 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: t\ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P I E: i$ <br /> Fee Amount: Amount Paid a 01GD Payment Date LA2 66 <br /> Payment Type �� Invoice# Check# I S 2- Received By: <br /> EHD 48-02-025 " .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />