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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEr'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />C e-inq /- rUCk <br />FACILITY ID # SERVICE REQUEST # <br />5koo 7716), <br />OWNER! OPERATOR <br />5alucAcloY Varlo e_e(rC .c <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />()C4r1C1 IL)F <br />SITE ADDRESS -7 3 i <br />Street Number <br />,, <br />Direction <br />so c(cArvic 4 FO <br />Street Name <br />) 0 cl ,. <br />City <br />qszei‘; <br />Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) P w tt 2 <br />Street Number <br />4 00d YO CO <br />Street Name <br />CITY STATE ZIP <br />I 0 ci , <br />PHONE #1 Err. <br />(?C'Ci ) .7"/ -q 7 2 5 <br />APN # <br />DLO 1 -5D 1 ii <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2a) 5 7 o - V 6 Set <br />BOS DISTRICT <br />oo 14 <br />LOCATION CODE <br />02- <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Sce/vo 016 V - <br />CHECK if BILLING ADDRESS CHECK <br />BUSINESS Nn <br />(PI U' Or (401 (Lipan 4 <br />PHONE # <br />(20-7)3 7/ -C47 Z5 <br />EXT. <br />HONE or MAILING ADDRESS <br />CI 61 1 CA)°Od Ye LA) <br />Fax # <br />Crry 1 I 0 C <br />STATE <br />,A( 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: DATE: 0 Li 6-// 7 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER Et- 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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: Ve • 1/C1-,Lc-L year' 0.---N RECE, <br />COMMENTS: 1 cf.: ij <br />ti 6 2011 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />ACCEPTED BY: ILA tv+0 ce,ItA EMPLOYEE #: DATE: <br />ASSIGNED TO: tov .„1"6 ..(4_ EMPLOYEE #: DATE: k-k - 6 -1-1 <br />Date Service Completed (if already completed): SERVICE CODE: 06 ( PIE: <br />Fee Amount:04 134 .00 Amount Paid Payment Date q /, / i 7 <br />Payment Type juik..., Invoice # Check # Received By: 126 <br />Title <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08