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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID #(-) (-,SET/ICE REQUEST it_ <br />IS Opv-85//5 <br />OWNER / OPERATOR CHECK if <br />A Si( PiV.A.X4 0 AAVAIre Z.- <br />BILLING ADDRESS <br />FACILITY NAME <br />Sck /( 4M- 22-7 <br />SITE ADDRESS <br />CO Street Number I Direction <br />___,..S--1-t-- A - s At - iTh <br />Street Name <br />N1c-c.-.5 10 <br />City <br />elc3C 1-1 <br />Zip Code <br />HOME of MAILING ADDRESS (If Different from Site Address) <br />'P - 0 (7)(:,)( S3q Street Number Street Name <br />CITY STATE ZIP <br />V•ir e S )--k-e -1 C CA. CA S "7", ...;,..--1... <br />PHONE #1 EXT. <br />( 2t.'"A) al 2 -GI SI, <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Lai kt\ryokrvQ-( 41 VO Alr II CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />r/(4k _S 0 4- ('C5)) <br />PHONE # <br />('C5))V- )) -9--(f EXT. /5(0, <br />HOME or MAILING ADDRESS ‘---po <br /> I (/' k S 1/ <br />FAX # <br />( ) <br />CITY Lb s ., e, STATE CA ZIP (I -3 p <br />BILLING ACKNOW DGEMENT: 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 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. <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY / BUSINESS OWNER a OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <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 /> <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it ISP to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: "LID( C-OACA/ k7/Lirk/CV \__. <br />COMMENTS: r NOV 0 9 2018 SAN JoAQuilti EltiVifio - couN <br />///AL-rhi DeivA4ENTAL T/' pARTAiAn. <br />DATE: iliglit <br />DATE: <br />ACCEPTED BY: U . e--61 Vt-e/VZ c EMPLOYEE #: <br />ASSIGNED TO: C; . Gavy/octi, k, EMPLOYEE #: <br />Date Service Completed (if already computed): SERVICE CODE: CX42 k, PIE: \V)-Z... <br />Fee Amount: 4 k9 z 00 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08 <br /><Pg-k25-Li.394e