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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH OtIPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />tOd ThuC V-__ <br />FACILITY ID # <br />FAOCO *53 56 <br />_ SERVICE REQUEST # <br />(- ,CX 7 564 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESSc, <br />Street Number' Direction <br />te-)- t <br />Street Name <br />-r-TV CA L_ lj <br />Cltv <br />el C3 7 (_- <br />Zip Code <br />HOME OE MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cirv STATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2#2 Ext <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESSr2/ <br />BUSINESS NAME 11,, i <br />L. ei• Icik-,-L r oN) ok_ <br />PHONE # <br />( il ut g)-3 <br />EXT. <br />HOME or MAILING ADDRESS Fax # <br />CITY STATE 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 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: P\-A9Y CAM Po AY kj,)-6-1 DATE: 1 20\1- <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER/El/ 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 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. YMENT <br />TYPE OF SERVICE REQUESTED: 6,9 tialtU42- 41 i-i'l>n RECEIVED <br />COMMENTS: A 7 <br />2,v vaLa.le_ DEL 1 9 1017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT, <br />ACCEPTED BY: hcAxt 0 tiejtov EMPLOYEE #: DATE: I 2 _ 72,1 .._ 17 <br />ASSIGNED TO: L'if, kafec7 EMPLOYEE #: DATE: ( 2 ...,Z9 ...1 7 <br />Date Service Completed (if already completed): SERVICE CODE: 06 I PIE: 16°3 <br />Fee Amount: i) ) c 2, co Amount Paid Payment Date / (• 4 1 1 .--7 i I <br />Payment Type ,..j‘,. .2) 1,-1 Invoice # Check # Received By: <br />--- ) <br />Title <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08