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FEB/07/2008/THU 05; 12 PM HHIsign Group FAX No. 916 771 55 P, 003 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or rope rty FACILITY ID# SERVICE REQUEST# <br /> I(v.• vICA. nd q33 <br /> OWNER I OPERATORCHECK If UNG DDR <br /> L1=5 C] <br /> It <br /> FACILITY NAME CI <br /> SITEADDREss <br /> sftredtNum60 i",,Jon treat Naime Ci ZI ode <br /> HOME or MAILIN OURESS (I IEP rent from Site Addrass) Street N1 ne) <br /> S IIy_ <br /> .J Street d her <br /> CIN STATEC ZIP <br /> P OKE#1 EXT• APN# LAND USE APPLICATION# <br /> k�A) M Oda <br /> PHONE#2 ExT. 1305 DISTRICT LOCATION CODE <br /> CONTRACTOR,/SERVICE REQUESTOR nn <br /> REQUEATOR CHECK If BILLING YS 0 DR <br /> 1 P NEI# ExT. <br /> kgUs{NESS NAME 1Y�,� <br /> HOME or IUTAILINO AdORES3 �b � �� 1 <br /> CITY llV( l STATE r ZIP l <br /> BILLING ACICNO'WLEDGEMENT: I, the undersigned property or buslneSS owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRDNMENTAL HFALTN 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,STA E and FEDRAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER LJ OPERATOR/INAN#: hen <br /> OTHER AUTHORIZED AGENT <br /> If APPLICANT is not Ehe,BILLING PARTE; uthorkation to sign iS required rare <br /> AUTHORIZATION TO RELEASE INFORMATi Iapplicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geatechnical data and/or environmental/sits assessment <br /> information to the SAN JOAQUIN COUNTY ENV[RUNMENTAL HEALTH DEPARTMENT as soon as it is available andel at/t�ll��atAr time it is <br /> provided to me or my represcntative. �} �V <br /> TYPE OF SERVICE REQUESTED: R r <br /> COMMENTS: SAN JOAQUIN COUNN <br /> ME <br /> ENJIFIONNTAENT <br /> N�UTN pEpARTM <br /> ACCEPTED BY; EMPLOYEE#: DATE: <br /> ASSIGNED TO: may` <br /> EMPLOYEE �LIM ��� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 <br /> Fee Amount: CIO Amount Paid 4• Payment Date 2— <br /> Payment <br /> Payment Type Invoice# Check# 3 0 Fiecelved By: N C--- <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />