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SAN JOAQUL -OUNTY ENVIRONMENTAL HEALTH -PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />a(2• 0011 UV <br />OWNER / OPERATOR <br />ROt Oln CLO ()/1 iqh IVI-Q11(tO CHECK if BILLING ADDRESS <br />FAciLrry NAME 10v\. oLe ( it s ct I /1_ S <br />SITE ADDRESS -1 3t) <br />Street Number <br />S <br />Direction <br />Ca Gi vt i m.. S4-- <br />Street Name City Zio Code <br />HOME or MAILING ADDRESS 'If Different from Site Address) <br />-2g 1-S L. oavvt 4> <br />1244 Street Number Street Name <br />CITY <br />--J\1--kr--1 <br />STATE aels ZIP ot s -lc) s <br />PHONE #1 Exr. <br />-U'\) U \g " -7-2-- (-I 2- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Ro \ A tra 0 Mok_.11 1 .) M_12. ()-61--- <br />CHECK if BILLING ADDRESS 111 <br />BUSINESS NAME <br />1 'IPI Ue 4 lik cke ks cmjskS pRolipt EXT. <br />HOME or MAILING ADDRESS FAx# <br />CITY .1-;)17,,,r..,3 STATE CA ZIP CiS7 0 S <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 HEAI,TH DEPARTMENT hourly charges associated with this project <br />or 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: 3 EA a c\ DATE: <br />PROPERTY / BUSINESS OWNER 0 <br /> <br />OPERATOR / MANAGER El 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 prope I2cated at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environment sifq sment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Rai VOV\AQ \„Aveckt5-\"_ <br /> 18 <br />20/8 COMMENTS: ,J0A, <br />"444g,cciuNco,, <br />."47` <br />ACCEPTED BY: \I (NADA°, Y1,0 EMPLOYEE #: DATE: t 0 i j lq <br />ASSIGNED TO: Of\ . --p EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Cy.0 1 PIE:14,03 <br />Fee Amount: cp ts-L _-- Amount Paid ( - - a 0--- Payment Date 1 0 ( <br />Payment Type 1(:{;;;11 Invoice # Check # Received By: i7 — <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003