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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />.-- A cA (x) C f u (1 <br />FACILITY ID # <br />F-n o2-?•) 2La. <br />SERVICE REQUEST # <br />OWN / OPERATOR <br />N V1( ei a rk \C* U 1 I 1-(u_c_i) CHECK if BILLING ADDRESS <br />FACILITY NAME <br />0 5 <br />N <br />"tr- r VIC( -C <br /> <br />" Cq e't <br />SITE ADDRESS <br />/ 3c1 Street Number I Zation <br />..,-.) <br />S Ct. C11.:( yareta-ce, -- 4 Lo 4 City <br />q_5-2z,1 0 <br />zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />.4-37,7r2,_ Street Number <br />( a* ?-s4- C24 <br />Street Name <br />CITY s AT i ZIP <br />q '7)-- -2 D <br />PHONE #1 Exr, <br />317 4 1 ki I <br />APN # LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />UCA VI t et k REQUESTORrN W <br />bal N 4 V( Ikj C46 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />IqUe.(-N COO-Cn Aattide- <br />PHONE # <br />(7-0‘0 27 b/ ki / <br />EXT. <br />HOME or MAILING ADDRESS <br />5A/3 2- (C rt \ L r <br />FAX # <br />CITY Lo 0 c ST(Atp.. ZIP 41 <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 thi icati'n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards E arril FEDERA laws. <br />APPLICANT'S SIGNATURE: DATE: ki 10 <br />PROPERTY! BUSINESS OWNER PERATOR / MANAG 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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: PAYMENT <br />COMMENTS: iiEuEIVED <br />APR 1 0 2018 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P / E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />07/17/08