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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ac)FCC -112-ALLCZ <br />FACILITY ID # SERVICE REQUEST # <br />(.(:1-C:-/ 7 S9 5 <br />OWNER / OPERATOR <br />DAN ICE-LE- STANDEe_S CHECK if BILLING ADDRESS 11 <br />FACILITY NAME <br />1 1-L4 ir 2_0% <br />SITE ADDRESS 2 0 i <br />Street Number <br />/Q <br />Direction 3 ia j5 c:")-r Street Name 0 A 41>ALE- <br />City <br />953 c- / <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />15 10 A ST c- STE IN 4t- I 2-q Street Number Street Name <br />CITY STATE ZIP <br />Oft 1:1) At-z_ CA- ' 7 5 3 4, 1 <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 #2 Ex-r. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR ...7 <br />1--)011•11 C-Li r Ss A i•-) DEA- S <br />CHECK if BILLING ADDRESSO <br />w AmomNIcr.6AILI 57_,4 I/ 1 FL1 PHO <br />o <br />N4 # EXT.BUSINESSNAME <br />(Z ) 602-- -7a 3.5- <br />HOME or MAILING ADDRESS <br />15-70 EAST" F- SrC A- 4# 12_1 <br />Fax # <br />( ) <br />Crry O A K-DAL_i_ C-ft- <br />STATE 53_3 6 I 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 <br />or 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, and F DERAL laws <br />APPLICANT'S SIGNATURE: / <br />DATE: 7-7-1 -7 <br />PROPERTY / BUSINESS OWNER 0 TO NAGER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not th ING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: V-c-2,cr Cc2.7)11 (,..c ( -la -j if, 1041 COMMENTS:?' <br />) LIC_ 41- Lt b-2_() <br />N V.) ifte‘ ji <br />Ift ‘j 1 V <br />I <br />sN esovil ovr),' <br />ACCEPTED BY: 47....w' A (zi EMPLOYEE #: - , N.:1`6 DATE: Tktis- 7 - or <br />ASSIGNED TO: ‘.....)Ni l h cLA ...u3 EMPLOYEE #: DATE: 7 717 <br />Date Service Completed (if already completed): SERVICE CODE: No I P1 E: / &CO__ <br />Fee Amount: ) -3,..) — Amount Paid A, t 5 2_ _ Payment Date 7 \ 7 \il t 7 1 <br />Payment Type V cs.c., Invoice # Check # 0 "5 3 A Recei ed <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)