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FACILITY ID # <br />i+-17q <br />Type of Business or Property SERVICE REQUEST # <br />IZcc ,`,2 93 <br />OWNER! OPERATIOR <br />Vu ) 1N(ct.ot <br />3 FADLIT fyclie-es., C' <br />SITE ADDRESS <br />Street Number Direction <br />CHECK if BILLING ADDRESS El <br />_ <br />Cl s Zin ode CI Silt) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />i —7 Z >— ('TT IA 1-) C Street Number Street Name <br />Gin,...-- STATE ZIP P i 1-, C.,(c),(c. c'pi 675 -7 s ? <br />PHONE #1 T. <br />(Ct ( (4' (L )— <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOIR <br />VIA i C CI . N <br />CHECK if BILLING ADDRESS .11, <br />.‘ I <br />BUSINESS .NAM 1 <br />ri`e h L.17 )C -)1(7 r..--,'---) C et Veil VI r." CV I CC.2 <br />PHONE # <br />(1(c4 el / 7 <br />HOME or MAILING ADDRESS <br />12-c L.--'=> elc,4-c)rtek_ Dr <br />( ..1 FAX # <br />( ) <br />CITY --- I L LircAic C4 STATE ziP <br />c :c -7 Sc' <br />DATE: I ( L <br />PROPERTY / BUSINESS OWNER EC OR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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 />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. <br />TYPE OF SERVICE REQUESTED: F-oc( hi/2icie_ ,,p7f,,,oeci--7,,,,..v7 RECEIVED <br />COMMENTS: NOV 23 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: .ae di-67 EMPLOYEE #: DATE: i / , / <br />ASSIGNED TO : (Nif)7164 EMPLOYEE #: DATE: j ) _ .D - /C.? <br />Date Service Completed (if already completed): SERVICE CODE: (4,..., ( PIE: j <br />Fee Amount: <br />j •q('( <br />Amount Paid i 3 ai • C9 (--/ Payment Date <br />Payment Type Invoice # Check # Received By: <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 />APPLICANT'S SIGNATURE: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08