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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> 5A� U INe,+AI <br /> FAcum NAIVE <br /> IEAooRESS Z5 y$ F. 54 air✓ "W ElAr' 'Ir- �.�16 I6Z3 o <br /> Street Number Direction S r <br /> Siest Name Ci 2'r Cade <br /> HOME or MAILING AoDRESS (If Different from Site Address) <br /> k t 03 E co Lt'a e l; J, Street Number Street Name <br /> zip <br /> Crnr L�n�eA STATE <br /> 476 23� <br /> Exr. APP# LAND UsE APPLICATION X <br /> PHM#r , X07 117- 130-06 fp - 06 - 51-) <br /> PFIONE <br /> EXT. SOS DISTRICT LOCAT1flN CODE <br /> { <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS E <br /> A („1 o n 5.e= LI C <br /> BUSt1dESS NAME PHONE# EXT. <br /> I1o�i (VI t^ o a3 - G613 <br /> HomE or MauNG ADDRESS Fax# <br /> ox 21�o 0�2` <br /> CITY L 0 r7.1 STA' ZIP <br /> CA q3 <br /> ILLING 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 /> 1or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN IOAQUtN .. <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 1 DATE: "(AO7� <br /> pAOp TY BUSINESS OPERATOR I NIANAG ER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR proof of authorization to sign is required Title <br /> AUTHORJZATION TO RELEASE INFOILWATION: 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. PAY <br /> TYPE OF SERVICE REQUESTED: c 2> 1/0 Com— -S, RECEIVED <br /> CONUMS: 3� s-T� �z3/off A5 JAN 2 2 2007 <br /> Gvow <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> r�Q �l�- I �y` HEALTH DEPARTMENT <br /> ACCEPTED BY: V(�I Ute.( 62 EMPLOYEE#:P 2, DATE: / L <br /> ASSIGNED TO: Q ��Tr r EMPLOYEE#: 3-7 q DATE: ( 0'7 <br /> Date Service Completed (if already completed): SERVICE CODE:/ � 01E: z� 0 2— <br /> Fee <br /> Fee Amount: Lf-7 Amount Paid I-t s, Payment Date '-12-2- 0 9 <br /> Payment Type L� Invoice# Check# Sit Received 6y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />