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NANJOAQUIN UOUNTYENVIRONMENTALILEALI'HLEYARLIVILINI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> L A ^ CHECK If BILLING ADDRESS <br /> 1577. <br /> Qs <br /> FACILITY NAME <br /> 577 S A0 C <br /> SITE ADDRESS /Z/00 W'F_,5T /A 0 7RACy 9x377 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /63 f-ATON ,4✓E1116l E <br /> Street Number Street Name <br /> CITY _r9A <br /> C STATE CA ZIP / <br /> PHONE#1 ETAPN# LAND USE APPLICATION# <br /> (2491' 3S - 240- 14o - 24 P A_04; _ ?1a7 K / . <br /> PHONE#2 ET. BOS DISTRICTLOCA ION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DO/•, C/-�ESNE CHECKIfBILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C SnIE1 Co (,tLTi - 03 <br /> HOME Or MAILING ADDRESS FAX# <br /> . o • oX f ) GGe-zs98 <br /> CITY LO Lk- STATE C- ZIP 53 <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 ap Ii ti and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and FEPPJZAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ` 31 •-07 <br /> PROPERTY/BUSDNEss OWNER 11OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT in <br /> If APPLICANT is not the BILLING PAR Tr proof 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 /> 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:Sj/L Ju Ir4B/L/ry Jr774 D Y, AN 77ZArC WAPIAIZ:OUP E✓rE <br /> COMMENTS: cvtc✓ (/d 0 r sJ R E <br /> �,IsI� �y0m:l t, jpN 3 ] 2007 <br /> SA ENV RONME.t•1TAL <br /> "EALTH DEPARTMECIf <br /> ACCEPTEDBY: EMPLOYEr#: 6) DATE: l1 07 <br /> ASSIGNED TO: S' to D GL[—DS EMPLOYEE#: [ILD ( .J DATE: 3/ C7 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 2- I E:'2(�..o-i <br /> Fee Amount:-% y7S rnJ Amount Paid ;) Payment Date <br /> Payment Type � Invoice# Check# Received By: <br /> EHD 48-02-025 .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �' <br />