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SAN JOAQUIN F JNTY ENVIRONMENTAL HEALTH DI ITMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C'11-5 S-CA Tl WCabo o S K O () 5 Z 3 19 <br /> OWNER/OPERATOR <br /> `V"Z- . CHECK it BILLING ADpRESSO <br /> FACILITY NAME �CJ-kLU0. <br /> SITE ADDRESS 44 <br /> { IV �a�� 2. ^v ���r' - qs-Q-6 f <br /> atreet Number of Ion atreet Name city21 Code It <br /> HOME of MAILING ADDRESS (H Different from Site Address) <br /> '591% 15— <br /> Street Number "'' Slraet Name <br /> CITY �� _ STATE ZIP <br /> ✓t ec1L� 0-A 94588 <br /> PHONE V ExT' APN# LAND USE APPLICATION It <br /> (gar) .30"1 131 <br /> PHONE#2 EZT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR •[' <br /> M of-eL' t/yI ,4 CHECK If BILLING ADDRESS <br /> BUSINESS NAME p 1,�fe 1 / a PHONE# Ea*• <br /> Ald 1"t,¢u.uLf.2ur�u.eet 'rw�. 46 - 6203Q <br /> HOME Or MAILING ADDRESS �Qa4 FAX# <br /> it�llOL� I'M ) �2t3— l40o7(p . <br /> CITY S�ttkSTATE CA. ZIP Ki k. <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 <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,STATE and FEDERAL laws. <br /> AP.PLICANT'S SIGNA <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT rp `�k&itx.R D-� jkr'v <br /> If APPLICANT is not the BlLLINGPARTY.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 environmentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itt is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �) 0 <br /> COMMENTS: l �ea CA-� w� �S-b (Tre*5 l--e- AF AN-r <br /> Sg l;o lle LvtC�y&&� 4c 2Sb • IA& CEIVED, <br /> OCT 18 2007 <br /> N <br /> ACCEPTED BY: EMPLOYEE DATE: ENRON ENTAL, <br /> g1wTME <br /> ASSIGNED TO: 5 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: a3d <br /> Fee Amount: d- Amount Paid a�l'�' 00 . Payment Date `D 1 $ •� <br /> Payment Type Invoice# Check# 2 S� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17l20D3 <br />