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Jul 07 06 09: 48a Jeffrey C. Henley 714-739-1499 p. 17 <br /> SAN JOAQRCOUNTY ENYIRONMENTAI,HEALTH0.PARTIVIENT <br /> • SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property , <br /> L4 T <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME CZ—LO ZC�Z <br /> SITEADDRESS �L C—r-�4.�f L-til. Loa:. <br /> Streeer Direct n <br /> SreotN Ci Zi Code <br /> t Numb <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number St et N <br /> STATE ZIP <br /> CITY <br /> PHONE#1 EXT. APN S LAND USE APPLICATION# <br /> 1 <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BIwNG ADDRESS <br /> PHONE# ExT. <br /> BUSINESS NAME 1 ��� .ot l0 & — --T <br /> FAX# <br /> HOME or MAIUNG ADDRESS <br /> t S � 1 (G7) CO <br /> CITY STATE C� LP a Z� <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STAT L laws. <br /> APPLICANT'S SIGNATURE: DATE: LO( Co (OA- <br /> PROPERTY tBUSINFSS OWNE1i❑ OPERATOR AGER OTHER AUTHORIZED AGENT <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_ r�l <br /> TYPE OF SERVICE REQUESTED: ,\J G C <br /> COMMENTS: O 206 <br /> QU1N GO <br /> uo <br /> SP�N kIR0 AelAT <br /> KIM Nf <br /> DATE: <br /> ACCEPTED BY: EMPLOYEE#: Y l� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Datc Service Completed (if already completed)_ <br /> SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid q Payment Date '� TJ I (� <br /> Invoice# Received BY: (J G <br /> Payment Type Check# <br /> EHD 48-02-025 <br /> REVISED 11117/2003 <br /> ENVVNN'N"UN i !rALTf l <br /> _. -RERMJT/SERVI.GES <br />