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• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br /><- <br />FACILITY ID # SERVICE REQUEST # <br />Sec0 -p-113 1 <br />OWNER/ OPERATOR , <br />BILLING ADDRESS <br />, FACILITY NAME A 1 . --;-q\-(_5(_ <br />-- , ,t c_<- <br />- <br />- <br />---7--_—------(CCA- A OS LI= ( <br />SITE ADDRESS - .-.7 i <br />Streel 4uirker <br />i <br />Direction 1 UtrkziR5V\ 111.-11F— Street Name <br />Sj-z7cv-te--- <br />City Zip Code <br />HOME or MAILING ADDRESS (If Diffente rm Site Ad ess) <br />(2 lict. ‘--- ()c 0 1 , u e . Street Number Street Name <br />Crry 1 ._'TAg ZIP <br />r). • 9 -3 2Lci <br />PHONE #1 Err. <br />(9E4 C•C3R -9-671- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ki V t_AAA L o e_Z- <br />CHECK if BILLING ADDRESS <br />BUSINESS gAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS <br />. <br />FAX # <br />cITY `---1-.:1> V,A- ut) 44. STATE <br />Zip CI )2_ 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: _— <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 />2. —5 - <br /> <br />Title <br /> <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: VGC0 U•r1c,I./11-crA-1(...1.--1 <br />I 1-'1 I NW I 01.011 NI 11 <br />RECFIVED <br />COMMENTS: <br />1-t3 0 5 2016 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: P, sa; EMPLOYEE #: DATE: <br />DATE: <br />2/5-t c,, <br />45111,e7 <br />P I E: <br />ASSIGNED TO: KAOti- &cC,1 N04-1 EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: ,e...AN.42 1 <br />Fee Amount: b c -.4( 75 o Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)