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Jul 25 13 05:21 a Reliable Petr M 20C18458953 p.3 <br /> RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JUL 2 5 2013 <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID i� NTAL <br /> ��RVIC _ DEPA TMENT <br /> OWNER I OPERATOR <br /> x.fk� ��� CHECK f&LUNGADOREss❑ <br /> FACi-17Y NAmE } <br /> SCEADDRESS L{L1 0 <br /> Street.Lumbu Dire:twn �.Jy 13--I1,� <br /> Irea[Name C1 /Zip Code <br /> HOME or MAILING ADDRESS (If Offferent trom Site Address) <br /> Sveot Nulnbor Strcw Na <br /> Clrr me <br /> STATE: ZIP <br /> PHONE E�'T APN# <br /> ti �3 LAND 115E APP;ICATION Yf <br /> cal: ► o <br /> PRONE 42 Ex-. <br /> I , BOS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> CON'TR_ACTOR /SERVICE REQUESTOR <br /> r` � l t}�/"] <br /> u-, . V�`� r `l�-l� CNECR If BIL.L'VG ADDRESS <br /> BUSINESS NAMEPHONE# E - <br /> �L-L��ati��E Vel ' y'-U)-C ��✓�� 5 �� C.z/L -1 h( �q �'IS ���' <br /> I"lOMEorMA:uNGADDRESS 1`t 7j11 ►-;a�S"r`-S � _ - FAX# G <br /> C:TY V P I(J (a� I `/s- .5- <br /> D 3 <br /> !\��—���E STATE pA zip is-? <br /> BILLING ACKNOWLEDGEMENT: I, 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 JOAQUI:\ <br /> Cou,4TY Ordinance Codes,Standards.STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -�jr .t 1�7'6C N:Y— D.aTE: s <br /> PROPERTY/Bust\ESS OW\'ER❑ OPERATOR/MANAGER ❑ OTHF.RACI'MORPZF-DACEN-r-ElL,' 11� <br /> 1fApp'-IC.`INT is not the BILLING PARD'Proof of authoriZaltiorr 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/si•e assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 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: PAYMEN <br /> COMMENT.: C� <br /> 8 �° r��cz � >b- U 6 201 <br /> SAN JOAQUIN COL NTY <br /> ENVIROMENTAI. <br /> HEALTH DEP RTM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: G y ` ( EMPLOYEE#: DATE: - <br /> Date Service Completed (if all ompletey SERVICE CODE: P i E: n <br /> Fee Amount: `� Amount Paid —4) b Payment Date Z <br /> Payment Typej Invoice# Check# <br /> Received <br /> RED 025 <br /> RE`J1SED SED 1'1117I2003 v " SR FORM(Golden Rod) <br />