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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br /> <br />I <br />SERVICE REQUEST # <br /> <br />- -) — <br />OWNER / OPERATOR . , <br />Gin V) 1 ( C OCY ) DCL <br />CHECK if BiLLING ADDRESS <br />FACILITY NAME — <br />\ 6( C 0 .S in flke Of-e <br />SITE ADDRESS <br />i >0 i Street Number Direction <br />M C, ( a nri-e ItO 3-k" <br />Street Name <br />Look <br />City Zip Code <br />Ho E Or MAILING ADDRESS (If Different from Site Address) <br />'--1 O Street Number <br />, <br />CA pt ae 6 r <br />Street Name <br />CITY STATE ZIP <br />' ,i" '''• q s-.22/4 0 <br />PHONE #1 EXT. <br />4 1 0 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR rTh <br />-16101-ke Cali \ & e-- CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />c (k C 0 5 L-a Nk_v\--i-e- Pp% iiin .--- <br />EXT. LH g) <br />HOME or MAILING ADDRESS gIvItil FAX # <br />Crre <br /> <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: 4:715r-L,-;,/ 0, <br />PROPERTY / BUSINESS OWNER 0 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 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: OA Olitt fe, ....1-41, lilt (ti t; r ) PAYMENT <br />COMMENTS: RECEIVED <br />APR 1 0 2017 <br />SAN JOAQUIN COUNTY <br />E NVIRONMENTAL <br />ACCEPTED BY: ,_..ii , (i. iLtetiict,n r-MO-14-..... EMPLOYEE #: <br />MET{LTH 0.6,4,---,6:--mq 0 i 1 <br />ASSIGNED TO: Te f t 'IL/If/W.1g EMPLOYEE #: DATE: LI 10 I 1 <br />Date Service Completed (if already completed): SERVICE CODE: , cil ()Lei PIE: 1112 0 <br />Fee Amount: 41 1 61 Amount Paid -, (F--)9 r,-T) Payment Date !I <br />Payment Type 0)4,, Invoice # Check # Received By: -9 <br />DATE: <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)