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0 1 1 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R&TA-IL F0E L FACno2 5co 45/ <br /> OWNER/OPERATOR <br /> QO tll- S„r 0 P W A „ lC , CHECK If BILLING ADDRESS <br /> FACILITY NAME G j k it S-(-a fD 4, l q q <br /> SITE ADDRESS W E S T L Ar q p- S To c v T 00 cr S-2 t O <br /> 4-Z-+-L— Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �nLT'Q,t2�>h c f(i- S T <br /> _( !;,6 1- Street Number Street Name <br /> CITY <br /> ►�-�_ STATE ^ At <br /> IP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (5'(G) 6S'-- - 'FS-00 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,^,,�C(4 A-�' r ,IAL ( t <br /> �'1�' W V�`t CHECK If BILLING ADDRESS <br /> BUSINESS NAME �i/A`T o-.k �` ( ^(r (Z t r[ �' PHONE# Err. <br /> W 916 343— NI'rz— <br /> HOME or MAILING ADDRESS FAX# <br /> -1,;,, 0 • BBK m2S' w( 3- It Z. <br /> CITY W ^ l STATE (- A ZIP 9's-/ Cj <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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a DERAL laws. <br /> APPLICANT'S SIGNATURE: j�k- DATE: rs�/'�7-a /C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C y++r i R A-� <br /> If APPLICANT is not the BILLING PAR 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 /> TYPE OF SERVICE REQUESTED: P C ,47 Q 2 Ev r-( Yj <br /> COMMENTS: <br /> AUG Z 6 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPA T <br /> MPAm <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: I P/E:7 <br /> Fee Amount: �' Amount Paid � N) Payme t Date cy �!/O <br /> b <br /> Payment Type Invoice# Check# 3 $ Received By: N G <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />