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Apr 07 08 10:57a Sandra Barnhart 2098458586 p.3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G F ,�C,s7 3 '� <br /> OWNER/OPERATOR h <br /> e CHECK if 8il.tJtVG ADDRESSt <br /> FACILrrY NAME ra��C,,,- �����✓✓✓ u <br /> �..J/1 C� <br /> SREAE}DRESS t,P) /u "` �'(,�C t`( V __T_: f U IG 953/� <br /> Street Number Direction J Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Addross) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 _ Exr• APN# LAND USE APPt.icnnoN# <br /> PHONE 02 Ex'- BOS DismiCT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> .f 6 b r 13�i{Yrl t. 2 CHFCK iE Bit LIUG ADDREss❑ <br /> BUSINESS NAME J i-e { l e n S', `C.t�� C. - PHON <br /> HOME or MAILING ADDRESSr �-- FAX# r1 <br /> S-f - (a0 �l} Lf S - .(Q <br /> CITY f�jlf k\ �a i i STATE C+ ZIP �1t� 2 v f <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,JarATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I ' `�.7i c� / DATE: '113 ) rl <br /> PROPERTY/BUSINESS OWNER El OPERATOR I NIANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPpL1C4v7 is not the BALLING PARTY proof of authorization to sigis 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 DEPARTNiENT as soon as it is available and,at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE READ ESTEO: e- C�l:l a,1a—e S f 1 eck-f- \fZZ lir el C, cL l R, <br /> COMMENTS: , <br /> �} RECEIVED <br /> Loa�,A6 APR - 8 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAL <br /> ACCEPTED BY: ��! 1 ` t ?�� EMPLOYEE#: e;3 Z. DATE: q G' <br /> ASSIGNED To: { � EMPLOYEE W. 5 BATE: <br /> Date Service Completed Ikalready completed): SERVICECODE: (�� S�' P!E: _2 c <br /> Fee Amount: o-� Amount Paid ,;I-9y �. Payment Date 3I v g <br /> Payment Type j� Invoice# Check# Received By: <br /> EHD 48-02-025 �/�r�+ , g�g 3 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />