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3AINJLJAk2tJHN l,VU1V1 y r,174V1KU1v1V1P.111ia1, 1rvLE.InLGrell�ai.iur•i <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RES/DENTtA1– OPE <br /> OWNER I OPERATOR <br /> -L"1Kc. K if BILLING ADDRESS E] <br /> /'9R. e Mte f, Eatel F "D DENA Dr1 L ew a <br /> FACILITY NAME <br /> SITEADDRESS Vlra C.6-f/L/NA ESeALeAl 95320 <br /> Street Number Direction Street Name city Zip Code <br /> HOME orr/MAILING ADDRESS (If Different from Site Address) <br /> cF.9 (Q -A C44 ON Street Number Street Name <br /> CITU STATE ZIP <br /> E ScA /--0 nl GA �3 7-C) <br /> PHONE#1 E�' APN# LAND USE APPLICATION# <br /> ( ) 6o - 3692 /8 oo-¢ 'A - 03-ate <br /> PHONE#2 EaT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS Oal <br /> BUSINESS NAME✓ C� pNoNr# EXT, <br /> CyE NE CONS Ar/NC 03 <br /> HOME or MAILING ADDRESS FAX If <br /> P- 0 - 13oic 3 ( ) 6to9-ZS <br /> CITY Q L STATE ZIP / <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 or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this app 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and FE d laws. <br /> APPLICANT'S SIGNATURE: DATE-: �/O O 5— <br /> PROPERTY/13USINFSS OWNERO <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ ERADTHORIZED AGENT LYS <br /> JfAPPLICANT is not the BILLING PARTY proof of aut rization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 environnientaUsite 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: PERC FST /ZFPO/Zl— LC W,¢S� it dn1 <br /> COMMENTS: EIV E <br /> R <br /> R2 4 200 ,NN T usiq <br /> SAN JOAQUW C AL <br /> ENVIRpEPAR NT <br /> ACCEPTED BY: OL-tU�( EMPLOYEE <br /> #: e)3 DATE: �o O� <br /> ASSIGNED TO: I C)tpd EMPLOYEE#: �C��' DATE: <br /> Date Service Completed (if already complete Lo SERVICE CODE: �(o/ PIE: ,(2 02 <br /> Fee Amount: 19 3•o� X Z Amount Paid t ` •p� Payment Date I D Z OS <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />