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Mar 28 08 10:02a Sandra Barnhart 2098458586 p.3 <br /> w <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH)IJ ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GOSS <br /> OWN ER I OPERATOR ^, ��/ <br /> S�.5 5 c L r� (-�u CHECK If BILLING ADDRESS <br /> FACILITY NAME M li n r M c <br /> SITE ADDRESS / j � ! ' '� / i/! C3 <br /> Street Nrection Street Name 5de <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION 0 <br /> (a04) ��5r IL7� 7 <br /> PHONE G EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUE:STOR �r}� CHECK if BILLING ADD E s <br /> BusINESS NAMEiJ PHONE# <br /> HOPE or MAILING ADDR SSFAx# <br /> sal z aE��c�� J--'ah St. (a.)y K /S- W 5 <br /> CITY COL <br /> �& STATE cq ZIP <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 HFALTI-3 DEPARTntfNT 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,Standard STAB E and FERE laws. <br /> APPLICANT'S SIGNATURE:�L,( ty �L ,l,'L��� �.��"�� DATE: <br /> PROPERTY/RUSIN ES SOW-,, OPERATORINIANAGER ❑ OTHER AUTHORIZEnAGF,NTCOYIJyGL6-(,)C <br /> If.APPLIC.L4'T is not the BILLING PARrI,proof of autherfzation to sign is required Title <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMEt,-r as soon as it is available and at the sante time it is <br /> provided to me or my representative. c/-V- je <br /> TYPE OF SERVICE REQUESTED: e. ta,C FP PE-trc MLLbor q1 Pro d tt c--- <br /> cDt ,Ts: �, 04f- Fur <br /> Mq 2 8 Z048 <br /> SAN�o <br /> Ety�/gQON <br /> H�CTH EP ENTA�NT y <br /> ACCEPTED BY: EMPLOYEE#: 2 DATE: <br /> ASSIGNED TO: EMPLOYEE M / DATE: <br /> Bate Service Completed (if already completed): SERVICE COLE: O P f E. <br /> Fee Amount: j� Amount Paid �C ).lt 6D Payment Date 3 � IC)s <br /> Payment Type Invoice# # 2 4 Slo 6 1 Received By: k/l, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />