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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Typo of BusInuo or Property <br />1 <br />FACIUTY IDS SERVICE REQUESTS <br />71I (1 <br />OWNER 4 OPERATOR\ <br />CHECK If pILLING ADDRESS <br />Faciury NAME <br />al e,c CI-Qig <br />SITE ADDRESS -->.-_) <br />Street Numb r Direction <br />1\1 Streatham. <br />_.....- <br />1 rar-Ap; T:ag0 <br />HOME Or MAILING4DDRESS (If DI 1\ C, 1 GUI wvx. <br />Went fporn Sir*Address) <br />PM- '9 Street Number Street Name I- <br />CI STATE CITY \i,461, eit <br />kAA) <br />ZIP 64 i _70 <br />PHONE #1 EXT. <br />(A n )113 -ca35- <br />APN # LAND USE APPLICATION # <br />PHONE #2 Em. ' BOS DISTRICT <br />( ) <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (1,0 r.eif 0 ati, IN CHECK if BILLING ADDRESS <br />BUSINESS NAME \lira c+adl S14-4/(1 p.) P(rioN <br />A) <br /> <br />8 103 —S-03 S-- <br />EXT. <br />HOME or MAILING ADDRESS k , „ <br />n 1 c- C 1'740 61)i, Pie slf 14 <br />FAX # <br />( ) <br />CITY INIO,N) (1/4111 <br />STATE n.vb ZIP ii 4-1 1 <br />BILLING ACKNO 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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />CouNTy Ordinance Codes, Standar, Tkand FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNEIt) <br /> <br />DATE: F)1 <br /> <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If ARRLIcANT is not the BILLING PARTY proof of authoriz,ation 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 environmental/site sment <br />information to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ‘' ,_23 ‘N__;\ <br />COMMENTS: 44,J. ' J 208 <br />"JEAN/Roil Q‘44/ —14 77,/ • OA/4 CO/j, . <br />ACCEPTED BY: 115 fret CVt Airea EMPLOYEE #: -7 e0 DATE: ; -' <br />ASSIGNED TO: k....... '-‘, r...." \-\C\_ ( EMPLOYEE 0: ',--k Sk c-i DATE: -- 2 s-k Q <br />L., <br />Date Service Completed (it already completed): SERVICE CODE: Cjt, I PIE: <br />r Fee Amount: \ <E 2 Amount Pa /52 oD -- Payment Date ':--; k S <br />— Payment Type Invoice il h k eg4(--X.57//i Received By: <br />SR FORM (Golden Rod) END 48-02-025 <br />REVISED 11/17/2003