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Title <br />SAN JOAQI,... COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />(- 00 lin12-- <br />OWNER / OPERATOR . <br />Lo go g--4'64ur <br />CHECK if BILLING ADDRESS <br />FACILITY NAME A2/ "citt.L5 <br />SITE ADDRESS 7,, - I ,54-rk-1.,-) Direction s./-; ' Ft& Yd; ea Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />(/, 6^ .2 7 e-?---k 1-o1/_. ( 7 Street Number Street Name <br />Cirv <br />5.h34 Ind) <br /> <br />STATE ZIP <br /> <br />c'A -)5219 <br />PHONE #1 <br />(,2c9 ) go/ -7/ )c) <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i <br />UPPL}/f.> 4 tj b a," ) y <br />CHECK if BILLING ADDRESS 5 I <br />BUSINESS NAME ,,,, <br />- i------ P-71 6 e lig it __., <br />PHONE # <br />(Xi) 1/0/ - 7/0 C) <br />EXT. <br />HOME or MAILING ADDRESS <br />(e, &) 7 6-a-o ok- i-a_14-, CZ <br />FAX # <br />(zo) 911- do 5/3 <br />CITY lock/04 STATE _..41- 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 Of <br />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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, §TATE and FEDERAL laws. <br />'Yr? 4' DATE: <br />PROPERTY / BUSINESS OWNER , OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: - (...)()(ii nom 6"J-LeuK rrti nr.t...... <br />IVED <br />COMMENTS: A <br />FEB 0 1 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: pr <br />eL Mat6r264 oh EMPLOYEE #: DATE: ,41 1 1 ii <br />ASSIGNED To: n Ftm9rih J EMPLOYEE #: DATE: 2_ 1 1 i 11 <br />Date Service Completed (if already cempleted): SERVICE CODE: S C Coy- 2:6 PIE: Up 0 I <br />Fee Amount: IA 1-1 (1 47.2 CA SP Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE:,)( <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)