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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ChE✓RvV GAS fTA-nc,v ENovi SiZ-00 tO222 <br /> OWNER/OPERATOR <br /> I✓V(e) CHECK IT BILLING ADDRESS� <br /> FACILITY NAME I-AA-V*766A C—f+EVROU <br /> SITE ADDRE/SSSa 5 ` T Ac a/ <br /> S -r )V A,vTECA 95337 <br /> i l l0 Street Number Direction 1'\ Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) c. S uG ♦FICC -rE'FK"E <br /> zS2-3 Street Number Street No <br /> CITY Dui)L(U CA STATE Zip 9t56?tO/? <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> (* ) 925 -795 -2,m I Z0�ev- OC/ <br /> PHONE#2* EXT' BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> q� �ELf-- CHECK If BILLING ADDRESS <br /> 1\ ,[ <br /> BUSINESS NAME �(..(-� � f1-Sf L7CIPHONE# ExT'�-TEf SOS lr� '�2-�O <br /> HOME or MAILING ADDRESS FAX# <br /> 867 Phe I F(C ST. 5ut7� 120 ��/ ( ) <br /> CIN C� STATE 93�oj ZIP <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 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: <4'7 DATE: ((I r 916 <br /> PROPERTY/BUSINESS OWNER❑ OPERATp /MANAGER [3 OTHER AUTHORREDAGENT PP2/Lc(P•tt <br /> If APPLICANT IS not the BILLI 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: U-f� GL r/ <br /> heF— S -Tib I mo'L <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: Eno EMPLOYEE DATE: II <br /> Date Service Completed (if already completed): SERVICE CODE: SCS PIE: ',7�0 3 <br /> Fee Amount 12-'dt7 �ZIg2 Amount Paid Payment Date <br /> Payment Type Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />