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SAN JOAQUilv %.;OUNTY ENVIRONMENTAL HEALTH LL. ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />T(H) +IUOL--- ..---- A <br />FACILITY ID # <br />to cict • <br />SERVICE sRoaccim <br />CHECK if <br />REQUEST # <br />67 <br />BILLING ADDRESS <br />OWNER / OPERATOR <br />J ose OChoCA 0C-POCA <br />FACILITY NAME 1 (-A moy,--e. r, -1--L4 w o- <br />SITE ADDRESS <br />CP 2 f) Street Number Dirtion 5 aLycAtnougyvt-0 A- • ,od,,, 6150,4.4-0 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I 51.5 S 5 a uy o me nfo S itreet Number <br />I <br />Street Name <br />CITY STATE ZIP <br />L 0 d ) <br />AT <br />( (4 et 5- LI- 0 <br />PHONE #1 EXT. <br />(269) El..; - S 13 ‘ <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />(2 09 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />3 °`S-e- 0 C)(\ 0 CA 0 Coo- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME L ot INAD v--- Ki )--uk :I=F <br />PHONE # <br />(204 Le 5 1 ) <br />EXT. <br />HOME or MAILING ADDRESS <br />i5).• S 5 c A .L.Ir Gt .e_n 4-0 <br />Fax # <br />CITY 1 r)A1 p T Ar E ZIP Cli S -- '-F-L) <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 />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 />(S/Je( }(jL DATE: 0 1 0-1 APPLICANT'S SIGNATURE: I jx _,,,A <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 'nformation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 1)0 'I (1 SeC-111/V1 v VI I C V/ <br /> <br />Al„ <br />COMMENTS: <br />4r,,_ a;nek g.: 04A, <br />; •?,9 <br />iff -/Vt, 'IQ& <br />0 <br />`'it p 4Y04, /4' c <br />6'°Fp4f4794/11/4, <br />ACCEPTED BY: 0101 <br />C) ' <br />EMPLOYEE #: DATE: -.5 --) lig <br />ASSIGNED TO: cl t \-'J--EMPLOYEE #: DATE: -.5 7 1)67 <br />Date Service Comp eted (if already completed): SERVICE CODE: OU; ( P : IL 90 7 <br />Fee Amount: k 'at) Amount Pai 52, 6 ,0 Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08