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SEP -6-2006 10:26A FROM: D&SDRAGIINE SUC 2098268699 4683433 P.5 6 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE .REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE REQUEST # <br />- -15-7b <br />HOME or MAILING ADDRESS <br />3?' n <br />p <br />OWNER / OPERATOR <br />3TATrr zip C11 <br />CITY ; t) <br />t> b(o <br />n <br />f <br />1 <br />Fee Amount: �7i% 5 0 <br />CHECK If BiLLINO ADDRESSi i. <br />1 <br />J <br />Payment Type J --� S <br />Invoice # <br />FACILITY NAME <br />\` <br />SITE ADDRESS <br />ITrCk�Ca <br />� ! <br />L Strout Numbs, <br />e <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />street Number <br />Street Name <br />CITY <br />STATE <br />zip <br />PHONE#1 <br />(aa -1)83a- uqa <br />EXT. <br />ARN # <br />LAND USE APPLICATION # <br />PHONE 02 <br />Err. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOU.ESTOR <br />REQUEST R CHECK it BILLING Aapftes ® <br />BUSINESS NAME <br />PHONE# mT <br />SEP 6 2006 RUSH <br />SAN JOAQUIt4 G TALT`( <br />VAV1 C7 RTMENS <br />- -15-7b <br />HOME or MAILING ADDRESS <br />FAX # <br />ASSIGNED TO: W, N� <br />L� <br />EMPLOYEE#: U 7 S J <br />3TATrr zip C11 <br />CITY ; t) <br />t> b(o <br />BILLING AACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br />aelmowledge that all site and/or project specitiC ENWRONNIENTAL HEALTH DEPARTMENT hourly charges associated with this prpject <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 pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Crines, Standards ST and L laws. <br />APPLICANT'S SIGNATURE: — DATF: "i f (p jc6- <br />i,ixorRRTY / BusiNm, o%,%w A3 ERATOR / 'IANA( ER ❑ OTETrR AtmioRizrtD A(;ENT EL`S' C -i (y , i-. b� t IA.$,r lb I.i(�Q� I t � <br />tfAPPL1(',4NT is not the I31LL[,i .;PARTY. pros f of anthorizatitnr to sign is required Title <br />AUTHORIZATION TO RELEASE 1"ORMA7I0 : When applicable, L 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 />in OrinatiOn to the SAN JOAQUIN Coijwy ENVIRONMENTAL ):IEALTH DEP:wafENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OFSERMCEREOuESTED:�CJ�T <br />A,(�/iE <br />COMMENTS: <br />SEP 6 2006 RUSH <br />SAN JOAQUIt4 G TALT`( <br />VAV1 C7 RTMENS <br />Acce" p BY: (�� <br />I.OYEE #: 6-1 S <br />.gyp <br />ASSIGNED TO: W, N� <br />L� <br />EMPLOYEE#: U 7 S J <br />tDATE:— 6 —U(s <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />E: <br />Fee Amount: �7i% 5 0 <br />1 Amount Paid <br />(� 27 5--� <br />Payment Date ell —6 ._p(:::::, <br />Payment Type J --� S <br />Invoice # <br />�hedk'# LJ' ZS S ` <br />I Received By: G <br />EHD 48-02.025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />