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SAN JOA.IN COUNTY ENVIRONMENTAL HEALTH Lo...-ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A/1 o bite -R)crl --Fi ci ii+, <br />FACILITY ID # SERVICE REQUEST # <br />SR-00 -17q a 0 <br />OWNER! OPERATOR .____ <br />ljodsaL cold I ray( s \la 11 k-eu ire o CHECK if BILLING ADDRESS <br />FACILITY NAME <br />0 tA s-Q, Pi--z_ ---(ct.. Co ingt nti,. V A I ° V- 4 +at n 1-1 <br />SITE ADDRESS <br />2' ()O Street Number Direction t <br />Street Namel <br />OC kt)vi <br />City <br />q 5-2 os <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 2 3 23 1 vv. Pros veyi'G(acA L/J (t./) Street Number <br />"PI-Ds :e , 0 j c ribccx4 \A) a <br />Street Name <br />Crry , STATE ZIP <br />MCA/014-a-01 HO \--IS e CA q_5'3 9 / <br />PHONE #1 EXT. <br />(4O3 2_03- 2c, 3 tf <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(403) iiZ ( - I I/ ( <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i , <br />1 Vlaca j \jail 1(e (Ave 1,-1 CHECK if BILLING ADDRESS <br />BUSINESS NAME 1\110 Lt._ 1 . <br />vt-t---4'wi H 0 u Piz' r a_ C'Prii Fa frt vi P V,5# 7-- ( ) -0 <br />EXT. <br />- -2.e 2,14 <br />HOME or MAILING ADDRESS J <br />731 v.) Pr-Dspe ridad kAM-9 <br />Fax # <br />( ) <br />cITY M o vt 1/4 +el Yl \--(STATE GA ZIP (153* <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: —7/IS/V-1 <br />PROPERTY! BUSINESS OWNERS 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 pwner 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 />Title <br />TYPE OF SERVICE REQUESTED: f 00 D 0 COI Cin 7C( PAYME <br />COMMENTS: RECEP‘ <br />JUL 1 'J <br />SAN JOAQUIN <br />ENVIRONM <br />ACCEPTED BY: \--\ ern cm 1)2 EMPLOYEE #: DATE: -7 ttrilEPI6 <br />ASSIGNED TO: <br />\II kitt-- EMPLOYEE #: DATE: —7 3 <br />Date Service Completed (if already completed): SERVICE CODE: t3 ..._ PIE: PIE: (QC ( <br />Fee Amount: 4 54e 00 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />NT <br />ED <br />2017 <br />COUNTY <br />NTAL <br />RTMENT <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08