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SAN JOAQUIMPINTY ENVIRONMENTAL HEALTH.' ..ATMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />—FA 002A02-t <br />SERVICE REQUEST # <br />OWNER/OPERATOR <br />ClIaldi.C. 1 10(eS ShAtIS Cie-0 simee CHECK if BILLING ADDRESS <br />FACILITY NAME r 1 _I `-WVA15 T-OvVitA eat f'\. \/ Pa pitS-O2'I.,9L.... <br />SITE ADDRESS <br />rl 11 <br />Street Number S <br />Direction <br />Mon S-. <br />Street Name <br />stie-f..) <br />City <br />01520Lp <br />Zio Code <br />HOME or MAILING ADDRESS (If Different from Site Address) I gq LO <br />Street Number <br />C1 orcla \l-garier ci C <br />Street Name <br />CITY <br />11613 <br />STATE C4 ZIP <br />/74)La <br />PHONE #1 <br />(3) <br />Exr. <br />1)k); --- 44 (30 2 APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ( <br />2\ laelis .pio,"e5 S'In-i-os CHECK if BILLING ADDRESS <br />iBUSINESS NAME h? L.1 (40 GI o rcLQ,-.1 if .er., (-) <br />e(' <br />cri (.2 PHONE # <br />( ) <br />EXT. <br />HOME or MAIL 2 ,5S FAX # <br />( ) <br />j2.116 Cl \ 6101 Is --1-4 0 litor/A A \ig ?IAA P4C(401 - STATE OA 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, STATE d FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> <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 <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: tiNedk Vell((ilk..Q. \,\ASIZOtrY0-1-r— <br /> <br />REC,i"617. COMMENTS: /VED <br />IS <br />$ 20/9 AN J 1 <br />1,i,..A/ <br />H <br />V/R81•21 Coutvry <br />"11-T ClepivrE7VrAk <br />ACCEPTED BY: NI , v,,,Aa ,, EMPLOYEE #: <br />INT <br />DATE: <br />ASSIGNED TO: V . U A. VA VIS 5 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 (02 PIE: Ko o <br />Fee Amount: it, \ __- Amount Paid Payment Date <br />i <br />Payment Type i - , Invoice # Check # Received By: <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003