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JANJOAQUIN UOUN"1Y <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> �G5T AUILFFN SPo0 5 3 -232 <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS❑ <br /> 4 c ev T 8-12—P 1ZI S � <br /> FACILHY NAME <br /> SITE ADDRESS 12"} 5P2E Cte—5 �` I t`-IT C! n , CA 5 3 3 <br /> Street Number Direction Street Name city Zie Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> (� <br /> 'I L( r A rZ,m to 1fr43 Street Number A, Street Name <br /> CITY S jt�C tLToN STC DIPS 20 tv <br /> PHONE#f fir' APN# LAND USE APPLICATION# <br /> (2J-)J ) 31-46 - `1 22-1 - 2-60 _ 55 <br /> PHONE#Z ExT' BOS DISTRICT LOCATION DE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> HOME or MAILING ADDRESSFAX# <br /> �rtnn G FtS ft<L,o F ( ) <br /> CITY STATE 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,Standar s, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��itie1 `E� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORJZED 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. <br /> TYPE OF SERVICE REQUESTED: 7 � -I-Z u EU% R EC E I V E <br /> COMMENTS: JAN 2 8 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L Ill�t EMPLOYEE#: 2 / DATE: / C'e <br /> ASSIGNED TO: Al / –�Z_. EMPLOYEE#: E: ( Z. � ok7 <br /> Date Service Completed (if already completed): SERVICE CODE:L' P/Ey <br /> Fee Amount: Amount Paid Zf) ��• Ute~ Payment Date - <br /> Payment TypeInvoice# Check# Received By: `! <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />