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SAN JOAQURVOUNry ENVIRONMENTAL HEALTH I�ARTMENT <br />SERVICE REQUEST <br />Type of BusinessorProperty <br />FACILITY ID # <br />RECEIVED <br />MAR 18 2005 <br />SAN JOAQUIN COUN <br />SERVICE REQUEST # <br />�^ <br />LrOs� ; s r,sir, F0 C_ �J <br />FA -006 /480 <br />H <br />SRoa4�5�17 <br />OWNER I OPERATOR ////''''��t� <br />�� /C � i N r �rJor0.-i-,t Oh <br />CHECK if BILLING ADDRESS <br />FACIL1rY NAME, iL' I V <br />Y-'� U <br />SrRE ADDRESS <br />Date Service Completed (if already completed): <br />(1...1 'n �Sl� �Cl.. <br />SERVICE CODE: <br />� I'1 <br />P I E:.;2 G p <br />�I�� SbMi Numbw <br />Dlr.ctbn <br />' �-Crt� SbwtNiKt.Call <br />Payment Type <br />Invoice # <br />Zip Cab <br />HOME Or MAIUNG AnnpESs iN Different fmm Site Address) <br />R <br />Cm <br />w Mall <br />CA's qi3� <br />PHONE #t - <br />APN# <br />LAND USE APPLICATION0 <br />(�acs) al l <br />PHONE #2 E,n. <br />DOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR It SERVICE REQUESTOR <br />RE ESTOR <br />CHECK i/BILLING ADORES$ <br />h <br />Busnamq alINe r jon P q 1 5 85-$ 15� <br />HOME or MP&ING AD ES FAX# <br />2)06 �N ac_ erloot a0h585-0449 <br />Cm otivo,T8 - STA, zip 93a3o <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 ENVIRONMF,NTAi- HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will he billed to me or my business as identified on this lona. <br />1 also certify that 1 have prepared this application and that the work to be performed will he dont: in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />f <br />APPLICANT'S SIGNATUtfIM SP/�t�-ee l l `�L.L)QJL-t✓` S DATE: 3 <br />PROPERTY/ BUSINESS OWNERI61 OPERATOR/ MANAGER OTHER AUTHORIZED AGENT <br />//APPLICANT Is not the BIL/JNG PARTY proojof authorization to Sign i8 required Tilie <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaVsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTtt DEPARTMENT as seen as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SBR��v��IgCEE Reou; ED:' <br />,j <br />p <br />}0 9 j (Z. U 1 L - Q `i - Iq <br />Se <br />RECEIVED <br />MAR 18 2005 <br />SAN JOAQUIN COUN <br />ACCEPTED BY: CD" k,' J_ i <br />EMPLOYEE #: P 3 z I <br />H <br />N N US <br />A831aO® To: C 444,-� <br />EMPLOYEES: 8 -elf C, <br />DARE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/ c� s/ <br />P I E:.;2 G p <br />Fee Amount: �-� , cc'Amount <br />Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # O� <br />R <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />