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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> { SERVICE REQUEST <br /> SERVICE REQUEST# <br /> T of Business or Property FACILITY IQ# pp <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS <br /> {3o�3i3Y JO��Svts <br /> } <br /> FFAciuTy NAME <br /> y ADDRESS '�" [� !'-P l G t ROP 7 L l nl DE n1 5 Z3StrStreet NameCi Zi Code <br /> E or MAILING ADDRESS (If Different from Site Address) <br /> ;s <br /> S et Number Street Name <br /> STATE Zip <br /> CITY_ <br /> 4i. <br /> PHONE#1 Ex'r. APN# LAND USE APPLICATION# <br /> izo�l ¢sz 448- CIS - Zzo o <br /> -i PHONE#,? Ex-r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> L REQUESTOR I ✓C CHECK if BILLING ADDRESS <br /> 3 . r�C� <br /> PHONE# ExT. <br /> SUM NIESs NAME �l LW tJ /VI u IL P 63{ 33 —15613 <br /> = <br /> :HOME orMaluNG ADDRESS Fax# -72 <br /> (Zop) (9 <br /> CITY STATE CA)- ZIP <br /> t Ldnl 7 <br /> s <br /> ii 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 /> I or activity will be billed to me or my business as identified on this form. <br /> I 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,STAT ED <br /> s � DATE: <br /> APPLICANT'S SIGNATURE: <br /> ; . <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTrIOAIZED AGENT <br /> #; <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 /> s information to the SAN JOAQUfN 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: <br /> COMMENTS: ` f a// <br /> R 'c27 T � No� MAR 9 2006 <br /> r. 5Co77d 3 SAN <br /> / 8N�AQfJ1N QU <br /> TAL <br /> ACCEPTED BY: EMPLOYEE#: QATE: <br /> ASSIGNED TO: EMPLOYEE M. DATE: <br /> 't7 <br /> Date Service Completed (if already completed): SErtvict=CoDE: PI <br /> Fee Amount: C Amount Paid ` 6b Payment Date 3 <br /> Payment Typo Invoice# Check# Z Received By: C!� <br /> { SR FORM(Golden Rad) <br /> li z EHD 48-02-025 <br /> kEVISED 1111712003 <br />