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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ�/U}�ECS # <br /> DURAL E 1D / L �V I <br /> OWNER/OPERATOR <br /> MIT <br /> / A PF-AuA ?�O CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> / <br /> SITE ADDRESS 7�9 S 5 P.A Q A VrtV U 1F 07 ANS[A 9'5.33 7 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7/ 6--A 5T 5FDA� VEN4 E <br /> eet <br /> StrNumber Street Name <br /> CITY STATE ZIP <br /> 11 AN-r,r--GA. r-4 9S 3 37 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> go ) toot- ao 0".2G/00— <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> 4 FF <br /> BUSINESS NAME _ PHONE# EXT. <br /> 4 l-5NI= / 0 Z - 165.? <br /> HOME or MAILIN ADDRESS FAX# <br /> ( ) <br /> CITY L CJ-- <br /> - STATE `1A ZIP <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 ENViRONNMENTAL HEALTIi 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 ap at on and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance(.'odes,.Stcrnriarcis G TF. and F....F aI,laws. <br /> APPLICANT'S SIGNATURE: A;4� DATE: <br /> PROPERTY/Bt stNESS OVYNER❑ OPERATOR/MANAGER ❑ OT}IFR AUTHORizFD AGENT <br /> If.1 PP/.,IC'AVT is nol the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1, 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 ENVIRONNIFNTAL HEAL.Tti DEPARTMENT 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: /�Alsl OZAzCK P <br /> COMMENTS: T <br /> Cielve6 <br /> MAY 18 20?0 <br /> WRt EC <br /> 0NDUNN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: S1-1717'0Z0 <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: q.701 <br /> Fee Amount: Amount Paid �- Payment Date C� <br /> v C� <br /> Payment Type nvoice# 3 Check# Received By: v61-41 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />