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SAN JOALAulN COUNTY ENVIRONMENTAL HEALTh OEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />----' <br />SERVICE REQUEST <br />C -7 <br /># <br />'11°-) <br />OWNER! OPERATOR <br />CeCtcZ etm_i f-f-0 Mora\ QS CHECK if BILLING ADDRESS <br />NAME ... ' C i <br />CO \ I \ ) CI l G 1 CZA 1 6 <br />FACILITY tzektOfy) 1 Ck <br />Qic CA, . <br />SITEIDRESS <br />c/i u 0 Street Number <br />E` <br />Direction --\0,1cOk\ Stree wo--( ame <br />St0C0-6n <br />City <br />GI slos <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I 2 -D S U. .Jcl la.1 Street Number ,Q _A C ( \-- St ' Street Name <br />ClcUto c :.: \ on STA?, ec. Zip q5 20,3 <br />PHONE #1 EXT. <br />(-21)1) tAus-5 1-11 c <br />APN # <br />i (4N6116 ;2. <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />OM 6-M -LI 3o BOS DISTRICT LOCATION CODE 61 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORu _ ,---u--( bue, <br />(_ <br />r exo N..,13 ay? \c- <br />CHECK if BILLING ADDRESA <br />BUSINESS NAME1 a a js \I •Iva Ei 6,f u•--4 <br />PHONE # <br />(X9)110c- clq'T <br />EXT. <br />HOME or MAILINGtDRE . <br />(232- w\kSo0 w0L-( Pc-Vi-) <br />FAX # <br />( ) <br />CITY St0C,0-0(\ <br />STATE C p‘ ZIP q cv.---, <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 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 />APPLICANTS SIGNATURE: (\ ef ,g0,1 G ue i(C C) DATE: 0-14(d--1 n- <br />PROPERTY / BUSINESS OWNER)1( 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 info ation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided t <br />my representative. °Air <br />VEL) <br />201? <br />OtjAir , <br />7-,ei t • <br />MENT <br />Title <br />TYPE OF SERVICE REQUESTED: --(X) c-c. \),Q f,-) I r ) .e I / 7S ped--1 Ok) <br />C <br />COMMENTS: <br />-E_ Ob 0 , il erSki- V CLV)ci r19 () <br />DEC e, 2 <br />SAN <br />iv EvI R llY ( h'S.At rbi OAllifi <br />ACCEPTED BY::_ BY: '(T EMPLOYEE #: DATE: ) ,D,,..,.... / 7 <br />ASSIGNED TO: <br />n Vi <br />EMPLOYEE #: DATE: ),.., . / 7 <br />Date Service Completed (if already completed): SERVICE CODE: b lc ) P/E: ) <br />Fee Amount: IC-3 .2_04) Amount Pal X?, O0 Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08