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SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTH tiEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ri, k--„,,-, I, ( , <br />FACILITY ID # <br />i\)eu) <br />SERVICE REQUEST # <br />5Koo-2.s9) <br />OWNER! OPERATOR _ <br />^Vial. 1 u-,3 C 0\0 refs cr <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />4Sa" V 1-S.Sc_i_li- <br />SITE ADDRESS <br /> Street Number Direon 1 " IC1-117 ' <br />, t <br />—/ <br />i t t <br />-(,, <br /> <br />City Zisp'Code . I <br />'[1 <br />•:----)1-CL----4-0/1 9 `S 7-- <br />Street Name <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />) 'N) l'ket4--e ric./ C"\\IC Street Number TP5 Street Name <br />CI . 1 <br />S +nr\-',Voil <br />STATE ZIP <br />Cn_ q 5 7 CA <br />PHONE #1 EXT. <br />(2°9 6 S - 35 a 2 <br />APN # <br />1 eatio) --?_. <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />O () J <br />LOCATION CODE <br />10 / <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />I c.,, r a , /1 7C, (C A'19 V , <br />CHECK if BILLING ADDRESZ <br />BUSINESS NAME 1 . Ac. C) <br />Z./ I) C._ C 553 all Tr( ,:i le. r; <br />PHONE # <br />( 20C( ) c921 /4,-- <br />EXT. <br />HOME or MAILING ADDRESS <br />2:0G - E k•-k .vilelr eilic . <br />FAX # <br />( ) <br />CITY 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 Of <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 aid FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY / BUSINESS OWNER El OPE ATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 />TYPE OF SERVICE REQUESTED: -if,c)ek V .0(1 1 c.,1 -e r1-5 4100 RECEIVED COMMENTS: <br />APR 12 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL. <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ...e..(- EMPLOYEE #: DATE: 4 -I 2., _ ) c6 <br />ASSIGNED TO ' 1_4 Ahot.fu ...i) EMPLOYEE #: DATE: 4.../a_ j v <br />Date Service Completed (if already completed): SERVICE CODE: c)(0 i PIE: i ceo_3 <br />Fee Amount: ....- 2_00 Amount Paid — <br /> <br />Payment Date Li .),71, , / g7\ <br />Payment Type Invoice # Check # Received By2E------ <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)