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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />i\O-?D, ILE t )°•D -WAX.- <br />FACILITY ID # (-- ERVICE REQUEST # <br />ino5C12. I <br />OWNER / OPERATOR <br />kPs.fttilt I i MitP-Ailvt4 illiT DEg- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />NWILINSIW C,R1-E- lilt' it 5 r-7 ci-(pg2 <br />SITC iarmorcc <br />. _.._,,,, ,,, , ............_ Direction <br />?LEASPINTI) h ic— <br />Street Name <br />Plft-01\0\) <br />City <br />11-13-lc (I% <br />Zip Code <br />HOME Or MAILING AD RRESS (If DiffeLent from Site Address) <br />LI ip '2_ Street Number <br /> C R QUilos-u... I <br />Street Name <br />CITY STATE ZIP <br />.1-9A1A-C \A Ca 'I c3-1 -1 <br />PHONE #1 EXT. <br />(51) lc Li <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(S10) 40 CO ''' <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR A. „to 006; \ i\itliatitiN Hfi-T-PE4-- <br />CHECK if BILLING ADDRESS p <br />BUSINESS NAME MOuprif E.-- Cfpf 1-1.-C, <br />PHONE # <br />(SU ) LW Is -S' to-c) <br />EXT. <br />HOME or MAILING ADDRESS <br />rt,ta-; I -Rbt-ik-- (11 <br />FAX # <br />( ) <br />CITY STATE 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 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 hat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE anl im .1AL aws. <br />/ <br />PE <br />Title <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <br />DATE: <br />ATOR / MANAGER Y1 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required <br />siothq <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located a <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pro <br />my representative. Jfrpq <br />bove <br />TYPE OF SERVICE REQUESTED: 1L1,64n- le -,?)(0 C61150 1104101 SA <br /> °My n , <br />COMMENTS: v 'Y 20 <br />/-144' V Vilibki1/4 CO <br />rii 13/P1114 7;4 /4141 Alfi+7-A, K. <br />DATE: 7/9//9 <br /> ACCEPTED BY: <br />1114 61 ' EMPLOYEE #: (7 3 3 0 <br />ASSIGNED TO: <br />K -1 C eaAl Cif L , EMPLOYEE #: DATE: 9 ii <br />Date Service Completed (if already completed): SERVICE CODE: (:)( 7, P/E: <br />Fee Amount: IS 60 Amount Paid 5 jcZ 0 (2) <br />i Payment Date ell? <br />Payment Type /A Invoice # Check # e:71() Lino -7 Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)