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SAN JOAQUifOUNTY ENVIRONMENTAL HEALOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property. FACILITY ID# SERVICE REQUEST# <br /> (ZEr l C, A,S c c I t,' E- �i�l-oo02�.3z. 590°-435gq <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 60t(& STO A-a/L&TS / C <br /> FACILITY NAME <br /> vIIL 7—O (p / 32-- <br /> SITE <br /> 3iSITE ADDRESS A SIA IM 6-fL. G A( _ S TO C V T-0 M9S 2 I of <br /> 3 S S-'�— Street Number Direction Street Name city T Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S A A&E Street Number Street Name <br /> CIT. STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C'A A�L , ,r� ��,r CHECK If BILLING ADDRESSED <br /> BUSINESS NAME W/ W �`l PHONE# EXT. <br /> (A/A (� I O "( E+�C�. 1nti:F�2l�C<< , C' q/b 3-4- 1lSZ <br /> HOME or MAILING ADDRESS FAX# <br /> . o - o OZ (9(6 ) � Z <br /> CITY I I I�is.r S�C Q A V.-P,, � STATE C A ZIP �S6 <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 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 EDERAL laws. <br /> APPLICANT°S SIGNATURE: DATE: 1 C( Q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C O►4.r)Z A4-4-0 2 <br /> If APPLICANT is not the BILLING 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 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 /> 051 <br /> TYPE OF SERVICE REQUESTED: A•ti( 'rZ E U I W C.f ST j2 ';— ;, i VED <br /> COMMENTS: ,� AUG, 19 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: lit/I I C" E (,L E L E EMPLOYEE#: 3s' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: ;4:7Amount Paid — Pa7 1yment Date g- �� <br /> Payment Type Invoice# Check# R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br />