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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH4PEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />)9-06 lcIP- I <br />SERVICE REQUEST # <br />sRtO 7 -7<) <br />OWNER! OPERATOR <br />A u/ b Cp R.o tkiSO-n4- CHECK if BILLING ADDRESS <br />FACILITY NAME—.. <br />Kixi. 1L)it-o-..) C <br />SITE ADDRESS <br />761/60)-wet Number Direction A) a 'S---irie 14"44gl 1- ILI Street Name <br />t-eil b / <br />City <br />?.0 2- <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />V49?) 60 4 '-. CI Sr S9 <br />APN # <br />0 toe6q 019 <br />LAND USE APPLICATION # <br />PHONE /12 EXT. BOS DISTRICT i LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR e---N <br />VAV i 15 1Z-0-#,J1 671-i CHECK if BILLING ADDRESS <br />BUSINESS 1$1,21 t.) fe,......‘,„ cs.v.4....±..„s. <br /> <br />4— 3 <br />, PHONE # <br />(0 4 t9T 9 <br />EXT. <br />HOME or JAILING ADDRESS <br />(6 4 a w ).../-rtk..-uitat--0.) LAJ 63411 <br />Fax # <br />( ) <br />CITY Atv bi STATEA4, ZIP cp 5, 15() <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, TAT d FEDERL laws. <br /> <br />DATE: <br />PROPERTY! BUSINESS OWNERg OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />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. PAVMIiur <br />TYPE OF SERVICE REQUESTED: 1-7:306 Val d -e <br />.. <br />J r-)i,e_c___hc)Y") RECEIVED <br />COMMENTS: <br />i\le_03 w,1-e.- FEB 1 5 2018 <br />cic, p LI i Fn- SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTEDBY. ' iZCi ro EMPLOYEE #: DATE: 01 - J c / X <br />ASSIGNED TO: Fra h al q EMPLOYEE #: C DATE: cP,, - i *S"-' / il <br />Date Service Completed (if already completed): SERVICE CODEO (:)/ P/E: 1 6 0 6 <br />Fee Amount: 1 D..,6) Amount Paid Payment Date <br />Payment Type N \s,A Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08