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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID // SERVICE REQUEST # <br />St2 DD2CA2-q <br />OWNER / Q.PRATOR <br />CHECK if A4 ''7 igrafri/i /)e.frfp / BILLING ADDRESS <br />FACILITY NAME--; _ , <br />/of (- C/ A./Vre <br />/ ? / / Street Number Direction <br />SITE ADDRESS_ <br /> e; 5 . 0 11 / 6W /street Warne City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/9 'Ye / /VA i- I / 2 Street Number Street Name <br />CIlly sle 4.7 STAT(.5/4 Zip <br />7C-KPO <br />PHONE #1 T. <br />(107 ) 792 - ,)"/ 9 <br />APN# LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />\en j A nr1.1 0 Tv\ Aril siA I v\. CHECK if BILLING ADDRESS <br />BUSINESS NAME- -j <br />7 4 CO5 e/ 61,cro PHONE # <br />(fel) 772-4/7,/, <br />EXT <br />HOME or MAILING ADDRESS <br />V-62/ /0 V 0 \1 04\X. <br />FAX # <br />/9 / c"iy <br />CITY —7-5 4 <I sTATF,./._ Zip c/5".-ecepel <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: ?,- <br /> <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 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the grope located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site le I:. information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same lite me or <br />my representative. <br />----, <br />TYPE OF OF SERVICE REQUESTED: .1_.-up \I Qigt vlsvec lnA) JUN 2 8 1,, <br />CU g COMMENTS: SAN ..40,01Q , , L <br />EA/if/Ro y/Ai cot, <br />HEALTH D AimEiv r N Y EPA /0. AL <br />IlItteNi- <br />ACCEPTED BY: \I . ritAbAkVA, 0 EMPLOYEE #: DATE: y i.7 1(1 <br />ASSIGNED TO: 9 . cA viivrt r)),, EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: OLp I P/E: 1 Lp b 5 <br />Fee Amount: 152 , n Amount Paid i -. . Cl) Payment Date (0 <br />Payment Type Invoice # Check # Received By:-.KteZD <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)