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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER <br />Z /17 DATE: <br />" <br />OPERATOR! MANAGER I-1 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />(2.. otIc6oGi1 /44 <br />OWNER / OPERATOR <br />ot9ele i-o u-ea7-1 nn ol t c1onka o CHECK if BILLING ADDRESS <br />FACILITY NAME .._ritcos ,i pill 1 50 vt 0 Ai .\\Xcii.eilk) <br />SITE ADDRESS <br />500 <br />Street Number Direction <br />1 -1-Y1 4i—. Qk-- r) Street Name 1 KO kad-0 <br />City <br />9 535(-1 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 1,2.... <br />Street Number <br />tittictml/Lce tr.) Street Name Ail <br />CITY MO (ASA VO STATE CA ZIP 01 s..3 s 1 <br />P ONE 1 EXT. <br />) (PO Z ''' 04 (a I <br />APN # LAND USE APPLICATION # <br />PHONE 42 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 1215-vey2,1,13 u, oft <br />MCI 1 d mph) CHECK if BILLING ADDRESS <br />BUSINESS NAME —1--A co 5 et <br />pAl5ni/1 L.7 <br />NONE # <br />AM) (p 0 2- <br />EXT. <br />rr4(19 1 <br />HOME or MAILING ADDRESS t/2 <br />5— Vt Y1 d,61, Vt a i..) hil <br />FAX # <br />( ) <br />CITY INA bOLOV° STATE CA. ZIP T535 I <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 EDERALJpWS. <br />APPLICA IS ot 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 loca at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses tjition <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it isifir <br />my representative. <br />TYPE OF SERVICE REQUESTED: 'Flpt)4(t VeAlt CAJ2 v‘_svezik 0 K- AP i n <br />u 207s COMMENTS: SAN ., — en ..c„,,AQuitv co/ , <br />A 1,v -NT.. Hp <br />—1°1/ <br />imion, , <br />c'ePA;N)At rii,TAfr <br />ACCEPTED BY: \(., 0( ovv2 VIA..) EMPLOYEE #: DATE: L —1 0.-qq <br />. ASSIGNED TO: Ni 6-awdo EMPLOYEE #: DATE: (.1.-1 O _4 9 <br />Date Service Completed (if already completed): SERVICE CODE: C;q0 (Pi") (p05 <br />Fee Amount: .It. 1 '.1 . 4 DD Amount Paid Payment Date /`), 1 <br />Payment Type Invoice # Check # Received <br />El <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08