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3 A .1VAQU[IN I.VUINI Y V 1VVIICVINN1L1V AAL FIL'ALA rf UL'I'Alf.1IVA1:1`I I <br /> 0- SERVICE REQU Es'r <br /> Type.of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Go-s 5�o\a Vx S -%v q 33 3 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> ova/� 3 <br /> SrrEADDRESS Z�0 112rnrn-� '�"��' ion 7�-Zp� <br /> Street Number Dlrectlon Street Name Clt ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Numbor Street Name <br /> CITY STATE ZIP <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> IZA) 477 alt <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTO]R <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM `l PHONE# EXT. <br /> Y`o 0 3 Z <br /> HOME Or MAILING ADDRESS FAX# <br /> lip 2-7 P== Lo CIA--\.-k ( ) Z/D 000 <br /> CITY L©&� STATE C,k- ZIP S Z <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1'onn. <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 JOAOUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FCDERAL laws. <br /> APPLICANT'S SIGNATURE: DATr• <br /> P1t01'Elt'I'V/BUSINF,SS OWNER❑ OPFRXF /MANAGER ❑ 01'111:8 AAI'rHoR1%FD AGENT' 3" <br /> ff lI PLfCANT iS not the BILLING PARTY,proof of authariZntion to sign is required rNc <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 HEAU11i DEPAR'rMEN'r 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: C LVED <br /> COMMENTS: RECEIVED 5 <br /> AUG 2005 SA�AViRONME"ANLN <br /> ry <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL,TY F{ <br /> ,7 In 14f:A j-rLj <br /> ACCEPTED BY: EMPLOYEE#: DATE: ' <br /> t(�5 C— <br /> AssIGNEDTO: M EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:,-2 r <br /> Fee Amount: / Amount Paid a Payment Date 1 �� <br /> Payment Type invoice# Checkit Le <br /> Red ived y: <br /> EHD 48-02-025 SR FORM(Gooden Rod) <br /> REVISED 11/17/2003 <br />