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d-Y,053)7(cl 7 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Residential X21 <br /> OWNER I OPERATOR <br /> Sandra Richards CHECK ifB11-1-imADDRESS <br /> � <br /> FActi m NAME <br /> SITEAWRESS 21318 Mann Rd Acampo 95220 <br /> Street Nun"r D4eciioet Street Name Cky zkp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 900 N Workman St, <br /> Sheat Number Staw Name <br /> CITY San Fernando TA 91340-1750 <br /> PHONE#1 Exr. APN# LUsE PucAnMit APou <br /> ( I (323)336-2490 AN°017-290-09-000 <br /> PtMOME <br /> 02 Exr. BOS DISTRICT LLocATum CODE <br /> ( I � 9q <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQtfESTOR <br /> Chris Trapp CHECK if BILLING ADDRESS Q <br /> BUSINESS NAME PHONE# (916)652-6549. <br /> HONE or MAILING ADDRESS 4590 Vista Drive FAX# <br /> ( D <br /> CrcY Loomis STATE CA zip 95650 <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 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 Jo AQt:w <br /> COUNTY Ordinance Codes,Standards,STATE and FEDeR: ws. pq <br /> APPLICANT'S SIGNATUI�� DATE: <br /> PROPERTI'1 BUSINESS OV<FR13 OPERATOR/ MAGE. OTHER ACTHORI7.ED AGENT <br /> !fAPPer ANT is not the B11.11.yG PARTY.proof of authorization to sign is required Title 0 <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property I tile??020 <br /> above site address, hereby authorize the re a of any and all results, geotechnical data and/or environmental/9 a, COV, <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same E?'io FrNry rY <br /> provided to me or my representative. '�RTMFNT <br /> TYPEOFSERVICE REQUESTED: Consultation Permit <br /> COMMENTS: Verlf/�! C3hriecIf)FZr o� v.lho►e l��cs �� �r��}!5r sy5-4es'vl fbaf 1✓') �1Jc�� !S bEcp <br /> I-1T[e :501 -J' Pf .5v5fem-s .f') 00"if;0:1 S!5t9rt/I t,sr15 So6willrPcl GIS T; l�rLj�IJlY <br /> Sys+ewi. pfc6iDYvl <br /> ACCEPTED BY: 2 L EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 3 D <br /> Date Service Completed (if already completed): SEtvICECODE: D 1 PIE: d Ua <br /> Fee Amount: �pZ Amount Pa Payment Date <br /> Payment Type 2Cl( Invoice# Check# ,;Z/ 6 Rec4ived By: <br /> EHD 48-02-025 SR FORM(Golden Rade <br /> REVISED 1111712003 <br />