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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# / rSERVICERE/QUESTT# <br /> :3 r�l W % Or'-�4 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAmw NAME <br /> SITE ADDRESS Zp� 5, JgGKTWF- POA-r> <br /> Street Number Direcdon Street Name Ci Zi Cade <br /> NOPE or MAILING ADDRESS (If Different from Site Address) 2A-I <br /> Street Number Street Name <br /> CITY F• „ ,- IN&q. ( STATE CA zIP qC 23o <br /> Pi1gE� �.p� IUN E.T. APN# LAND USE APPLICATION# 1 J <br /> I?ogl 'f79 -5373 FA— 04,-5Z <br /> PHoNE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR AF4✓G � <br /> CHECK if BILLING ADDRESS <br /> PHONE# E.I. <br /> BUSINESS NAME t <br /> DII,LOiJ MU�P>{y ?Irl 33¢-6613 <br /> HOPE or MAILING ADDRESSFAx <br /> P,O p„x � � <br /> so (Z ) <br /> CITY �1>/ G�/ STATE e-A 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 13 <br /> I,fAPPLICANT is no(rhe BALING 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 environmentallsite 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: S C I L S u rTY} 1 LIT S rZl D bRE 36 <br /> CONEWS: IJ-fiaa tJtR IVED <br /> I7�}i L DE< 31 <br /> 3a �J E ay y6a/.Sys- DEC 2 1 2006 SAN 41E)A4UIN <br /> ENVIRONM <br /> tvimtoSAN JOAQUIN COUNTY 4TNGp TM� <br /> ENVIRONMENTAL <br /> ` <br /> ACCEPTED BY: U L t J�r �A EMPLOYEE#: ��2- A �2 Z t <br /> ASSIGNED TO: X30 E,�LT EMPLOYEE '7'3'- 5 DATE: ( Z_ 21 OL- <br /> Date 'v <br /> Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I Cj ��. L� Amount Paid {-t2Rtt Payment Date <br /> Payment Type Invoice# Check# 13yfz (°;�j Received By: <br /> Melt_ ANb, <br /> EHD 48-02-025 1i 13t 1 D-j SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1 <br />