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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST <br /> OWNER I OPERATOR <br /> esse C CL Q IfBmLQ ' =nr: <br /> fAtlurYIVAME y05cmd'e• <br /> A-v n vc A d2c46 A #6� Ph <br /> SfrE AWREss / ) l >±' yose,#" vlt Amt✓e 1'l� +Ca. 9S3 3L <br /> streetlNumbar a c <br /> HQuIE or MAftNG ADDRESS (If Otffatent from Site Address) J ` N / <br /> sheat Number Vj r <br /> CITY STATE &P I / i > (J <br /> PRONE 01 Exr. APN # LAND Use APKccATM # Sq N y 282023 <br /> ( ► oq (2) 2 310 - 10 J�N � NM COUEN NT <br /> PWU #2 Ekr. Bos DLsrRlcr 03 LOCATM oa E Pq R rn�L r V <br /> C/ONTRACTOR / SERVICE REQUESTOR <br /> C"-7 <br /> REQUESTOR L) / Y641dCZ <br /> CreecXifBuw; AaaRsssa <br /> BUSINEss NAME PHONE F"r- <br /> HomE or MAwNG ADDRESS 36 1 S him C + <br /> Fog 4 , <br /> CfTy AM 4-QC / STATE C ,Q Z'P <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project spedlic ENVIRONpIENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in a000rdanoe with all Sow JoAcmw <br /> Coumy Onfmance Codes, Standards, STATE and FEDERAL laws. <br /> APPUCANT'S SIGNATURE: v 0 DATE: I 23 <br /> PROPERTY I BUstNE%%s OWNER OPERATOR / MANAGER 13 OTHER AUTHORIZED Ass 17 <br /> If AppercAm' /s not the SJUJNG PARTY proof of authorizai/on to sign Is required Title <br /> err iQgIZATION TO RELEASE INFORMATION : When applicable, 1, the owner or operator of the property located at the above <br /> slte address, hereby authorize the release of any and all results, geotechnical data and/or environmentattsite assessment Information <br /> to the SAN JDAQUN COEwRoNNMENTAL HEALTM�EPARTmENT as soon as it is available and at the same time it is provided me On <br /> ray representative. l iii — sL'KtZE 0 J AA <br /> TYPE OF SERVICE REQUESTED: T /��f, �l ' YJ �� `' <br /> COladFt & '7'u t^P�I �4CtG at /// / e ar/S`7� .y� ✓/ PAC Cud•• • /9S3 r s <br /> lit d1( ., e44jejrj ca ,A heuJ ✓eeZ /2no1 6.1.ee, S' s �iGw a � c� <br /> At V c/ Stie4r 02Ae4 7'0 evw.je 7 w �3�. S.3 INPC2) re arrer. � fA r ce a <br /> V��� hof s'of't �e cold S4;vf and � >'1/44Rte az// Tit Ale & der oil <br /> w49 'f 3SPO,3Z3 i ' � v.ev.j t/eeL auaT � 9Y38f7 - 208 ScLvn/S . <br /> ACCEPTED BY: h ` V J F�awYFrE #: DATE: I t1lz�5 <br /> AssieNED TO: ,� j ) EmPLOYEE p: DATE: <br /> Date Service Completed (H already completed): -� SEIIYICECGDE: ' `! PIE 23 <br /> Fee Amount• / ' ' _ Amount PaId4 PatPayment Date 11 2312<3 <br /> Payment Type �= Invoice # Check LO fo3 R cetive4l By: <br /> EHO 4"2w= SR FORM (Golden Rod) <br /> 07/17/06 <br />