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SAN JOAL A COUNTY ENVIRONMENTAL HEALTH -icPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property . FACILITY ID # <br />FA ()a -1(024 <br />, SERVICE REQUEST # <br />f ICUO -7112- (6 <br />OWNER/OPERATOR / _ r CHECK if BILLING ADDRESS <br />FACILITY <br />F-L e_.\ cot" ScO0er <br />SITE ADDRESS <br />2-0 00 Street Number Direction <br />111.1r SitCk -ir-n 5- I-fording Wa Stre31 Name City <br />cfs5..; <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />''-h .37 1-i-em-loon-) 4-1_,& Street Number Street Name <br />Crry ,acti Sm ZIP , <br />(-7 _ <br />PHONE #1 Exr. APN # I LAND USE APPLICATION # <br />PHONE #2 #2 EXT. <br />( 2.c%1) (04-17 - GiciC.)7 <br />Ii BOS DISTRICT <br />II <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / <br />1 :yu,q ra0,14)4 CHECK if BILLING ADDRESS <br />BUSIN-eSS NAME E i itiej6r s-abo r..._ PHONE # <br />(.Z) g 34 --7C00041-- <br />EXT . <br />HOME or MAyNG ADDRESS <br />Li I 3:4- 1 4C1 (1 Gun-) Lame <br />FAX # <br />( ) CITY -tracq STATE ct ZIP q C5 <br />BILLING ACKNOWLEDGEMENT: 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 td FEDERAL laws. <br />APPLICANT'S SIGNATURE: t <br />PROPERTY / BUSINESS OWNER El OVERATOR / 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 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. <br />TYPE OF SERVICE REQUESTED: DO& v&/1-V-Ae-- --‘,-/Pec--ti,Dtn 1 <br />COMMENTS: <br /> <br />il a <br />CE71 • ' <br />br O APR 8 A 7 2049 _SAN Jo. <br />ENVIirI QUIN Co <br /> <br />114477414E LI"V. DATE: ACCEPTED BY: /11 IA /40 /elk EMPLOYEE #: <br />ASSIGNED TO: i-k var k EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: IGO 5 <br />Fee Amount: 4) i 3'j 00 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: (3j17 <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)