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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />laC 00—YI SI 0-4-- <br />OWNER / OPERATOR <br />N. 1 A CHECK if C-1 ot eck'cA_, BILLING ADDRESS 12 C (..) <br />FACILITY NAME WID A vk G-1/4-oS 0 CA X 6 ut c v-N 0 <br />SITE ADDRESS (2 c; <br />Street Number Direction <br />c7,G1AA.ej ---y\— <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />q `-'t Street Number <br />-i---ii k . I fAAA S-f <br />Street Name <br />CITY STATE12/31 ZIP el s - <br />e <br />--, • 47")1C-1 U •,‘) <br />PHONE #1 EXT. <br />V\ ) 6tVt - M11-I <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />NIC\itC05 ClA e--C1C/\- CHECK if BILLING ADDRESS <br />BUSINESS NAME WI) (AAA ci\-u 5 0 ci x 4-1 viZeN ° <br />PHONE1 <br />C2-0 .i0 ) 171 T7+1-- 1 . <br />EXT <br />HOME or MAILING ADDRESS c 1. FAX # <br />CITY C-5\/V-1\-) STATE 0./ps ZIP alc.-70,0-140 <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: /1w-cc 5 cr <br />PROPERTY! BUSINESS OWNER El OPERATOR! MANAGER El 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 />PAY PM" I TYPE OF SERVICE REQUESTED: \) eh t cv \ v\9 vcckx,A.,--, *--00( <br />COMMENTS: RECEIVE! <br />'3 0 20' <br />SAN JOAQUIN COI ER <br />DO EN ph,kNTTt <br />NVT:HRt <br />HtACCEPTED DATE: <br />1 \ <br />BY: VY1 OV\QAA, \-.) EMPLOYEE #: <br />ASSIGNED TO: ' J / e 44 EMPLOYEE #: DATE: 10_1)0-1 <br />Date Service Completed (if already completee - SERVICE CODE: \ P/E: \ u0 2 <br />Fee Amount: A, k c71 _6,..) Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: <br />NTY <br />ENT <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)