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SAN JOAQUI�OUNTY ENVIRONMENTAL HEALTH,,.,PARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> F'Ty <br /> usiness or Property 6 O✓ <br /> OWNER/OPERATOR CHECK if BILLINGJDREss�-� <br /> AiJ11 'lIA-D-+AV <br /> AME 1 rA r.,O H 1�C I RESSVI't�`�J ��Ay+t�� yDfZ <br /> F C <br /> StreN Number Direction SReet Nam <br /> HOME or MAILING�ADDRESS (It DNfereAnt from Slte Add�SS) <br /> t' 1 L� fC� Street Numbet Street Name <br /> TATE <br /> Cl mP'n„ G S <br /> � L 1"V IV LAND USE APPLICATION# <br /> PHONE#1 EXT. APN# <br /> (SII:) r7C12 s�� 3 �%S <br /> Exi BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if wa H ADDRESS13 <br /> kNIL -yA-DAV <br /> ,�/ PHONE# p <br /> BUSINESS NAME ://Y�; +\ C "D BA .3�. 1� -(L b4 <br /> VrT f`t N FAX# <br /> WQMB: rMAILING ADDRESS 4 3v (Sf0)'7g2- 3''�SD <br /> CITY <br /> f�,A^h�1,STATE <br /> BIILING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENNIRLINmENTAL HEALTH DEr.ARTTv1HNT 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 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Owdalg <br /> IIpp DATE" ZC) IO <br /> PRopioin'/Bossism owNER� PSATOR/6faNACERpa OTHER ATnnowED AGENT❑ A -ezl� _ <br /> IfAPPUCI:VT is not the BILLJ. C,PAM"proof of autHorizatioo to sign is required Title <br /> AAUTHORIZATION TO RELEASE INFORMATION: When applicable,L 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 CoUN7'Y EMTRONmENTAL HEALTH DEP.ARTME TI'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: PAY <br /> COMMENTS: I( s 1s Cl new -x"64-4j "'Cil Wt (( IW- CM✓v►� �VED <br /> VoCt in fCAt bvX /Lrh hof u,Ym vtf APR 2 5 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALT <br /> AccEPTEo Br: EMPLOYEE#: U <br /> DATE: <br /> ASSIGNED TO: EJMPLOYEE#' DATE: <br /> Date Service Completed (N already completed): SERVICE COPIE: <br /> Fee Amount: '� Amount Paid RC1 g. Payment Date <br /> 66 <br /> Payment Type C9r6 Invoice# Check# `1k S Received By: <br /> EHD 48-02-025 �,�. may' SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> , 2/ q0 •. <br />