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JAN JOAQUINCOUNTYENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE kE UEST# <br /> AMuCULTL AL IAM5 tZ ZJ y 3 <br /> OWNER/OPERATOR <br /> DUCA CHECK If BILLING ADDRESS <br /> SAM LO <br /> FACanY NAME <br /> SITE ADDRESS _ -.ODUCA DRIVE - MANIECA 95336 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME Stre¢t Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> ( 209 ) 982-5185 204-120-18 jdsQ- - C)C 77 CM S <br /> PHONE#2 Ea- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> f � CHECK 11 BILLING ADDRESS <br /> HOME or MAILING ADDRESS 14* FA%# <br /> CITY STA 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 or <br /> 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,Stand rds,STA Id FED -law <br /> ✓APPLICANT'S SIGNATURE: DATE: 04/17/06 04/17/06 <br /> •v PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT KI PAMPMY <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tifte <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 /> 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 O L L Cur 7-A A I t, t N 1 ro—A7 £ C-o <br /> COMMENT : f ,-e�,�..-� CEIVE� <br /> o APR 1 7 2006 <br /> SAN IROUW COUNTY <br /> HEALTH pE A N//TAL <br /> ACCEPTED BY: O t-I OE Lel EMPLOYEE#: G 22 Z/ DATE: T /7 rO So <br /> ASSIGNED TO: O,EQ�7 EMPLOYEE#: 7-Z-- 9 DATE: Lf /-7 (0 (' <br /> Date Service Completed (if already completed): SERVICECODE: SZ S Pi : 2-1 _ C> <br /> Fee Amount: L5� Amount Paid 5 Payment Date y, <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />