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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # (----,„SERV,ICcrREQUEST# <br />OWNER! OPERATOR <br />CHECK if BIL LING ADDRESS L AV U 1 S Is004-)60 AVA.Vre Z- <br />FACILITY NAME <br />—.1 • • S564__ 1 0 -'6 0 9(t) f 4t 2.5? <br />SITE ADDRESS <br />500 Street Number Direction <br />--q--4r1 S + 5.t c . \-) <br />Street Name <br />OvaeS it) <br />City <br />95 35 1-( <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />(7.0 g (:))( C 3 `1 Street Number Street Name <br />Crry STATE ZIP <br />li\j'eSkit 1 C "lc C1S--B.4 <br />PHONE #1 EXT. <br />(2O) BIZ - 61 C 6 <br />APN # LAND USE APPLICATION # <br />PHONE 42 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR L • \AA S hyvlairth A 1 vcve z CHECK if BILLING ADDRESS <br />BUSINESS NAME c )0 ..14 <br />C Ci- # <br />PHONE # <br />( Ori) 2'73 -646o Exr <br />HOME or MAILING ADDRESS . }6 X 5 i',3-,' <br />FAX # <br />) <br /> <br />r , <br />CITY <br />\A SF )-.et4 <br />STATE Citt 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, STATE and FEDERAL laws. z,7 <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: 2 -05 - 20) Ci <br /> <br />PROPERTY! BUSINESS OWNER Tfr OPERATOR / MANAGE 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. P - <br />TYPE OF SERVICE REQUESTED: ik:6#17167 011 <br />COMMENTS: <br />ic4;9 Os s'INdo - 20/, iii 41,4 Q04, <br />tAt 7, 040,,S00,„ <br />rl D13,4177\1.7;41 7 1 ttinir <br />ACCEPTED BY: ( irt LAII ,c EMPLOYEE #: Ci .2)7', <br />I ..,/....) <br />DATE: <br />ASSIGNED TO: _C--„, (14.- EMPLOYEE #: DATE: <br />Date Service Completed .42,(1jSERVICE CODE: O (7 I <br />——.) <br />P/ • V :2 (if already completed): <br />Fee Amount: I oc Amount Paid /c---2 (51,, Payment Date <br />Payment Type(77-, Invoice # Check # Received By: <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)