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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />---00(3 -(aklo__. <br />FACILITY ID # SERVICE REQUEST # <br />00"--ictq97 <br />OWNER TOR <br />\ eh ( i `e5 CHECK if BILLING ADDRESS Er utf (31 <br />FACILITY NAME ho (1,6,5 r A „lac tc, <br />sri EA z s .., p . <br />(„; tti Street Number liTrion -111.2 (r.70 Paan)447!) <br />Lox Lox <br />City Zip Code <br />[IOW or MAkiNG ADDRfclifferent from - ite Adclre - v <br />Street Name L r a II YO 1-50) IF "At Street Number <br />Crry . (1; crA-119r) doe eTAi, cf4_ 25--‹-c- <br />EXT. PHONE #1 <br />( 2eq Lou Q__- u36-cl <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2N 7617 7 7q0 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REMCItiel ciar j e CHECK if BILLING ADDRESS Er <br />BusiNEr__Ir artee5 p ‘otee <br />P(I21 ii(i 2-- 035t) <br />1-10 7 .e.unDir s .2 ,c) ot FAX # <br />( ) <br />CITY k )3 nOd )01r 1- OICV C.,()- c1S2S534tE ZIP <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 ap tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S AT and FEDERAL la" <br /> <br />DATE: ,2 -3-1 <br />PROPERTY! BUSINESS OWNER 0 OPERAT R I 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 information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pierrl to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: -VC06 \I Q.,‘A,' k ci.Q kdru\A__ 4:03Z. 1,)if,:-,-,, wqe <br />OEC C„ <br />COMMENTS: <br />7 <br />NAM( 41 0,c- WANZAA1Aft p . eos 8141V, OA <br />: <br />„LIN ly,447._No„vmsotiv , <br />e,fri a r 1 es p la ce 30 1 8 e n ryi66 i - dory) PI ‘0 "Pdel14./7;eq, 1 r <br />/114 r <br />ACCEPTED BY: \.1 . NI, 0\AQ44,D EMPLOYEE #: DATE: k...2— 63.12 <br />ASSIGNED TO:0 . VI \frk ) EMPLOYEE #: DATE: <br />Date Service Comp eted (if already comp ted): SERVICE CODE: 0 LO P/E: N 0 <br />--,./ <br />-2, <br />Fee Amount: '2. -OD Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08