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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGE <br />SAN JOAQUL 20UNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business, or Property / <br />D <br />1111 C ki it 4 trai e_r o I <br />FACILITY ID # ,SERVICE REQUEST # <br />5 OoK/07 L { <br />OWNER! OPERAT <br />Al - (.-t1)(1 CHECK if BILLING ADDRESS L <br />FACiLITY NAME 1 I i . _ <br />'IA i (.t. . ,(:.5710—Q ..,...." . <br />SITE ADDRESS <br />Street Number Direction <br />/ <br />Street Name City ----1 Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Adles) 1 / t cif 9 1,0' <br />i IStre t Nurnbe4 C H Street Name q 5.2 LR c <br />CITY STATE ZIP <br />a(Cl 11) ? n <br />PHONE #1 EXT. <br />3Q 7 - C 5 537 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. Ii BOS <br />( ) <br />DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I <br />CHECK if BILLING ADDRESS u emr c PI- ,l'Ici If-'e__. ' <br /> <br />, :J BUSINESS NAME /1/ a r 3, 0 quer! C7 <br />pHoNyi (7( /) , ) , , 2 ,--)/-- <br />EXT. <br />HOME or MAILING ADDRESS „... <br />,•7. c)- illd <br />./ t Li A /11 ' ( 7 PAX # <br />( ) <br />cn-Yri » I)C STATE <br />r 14-- <br />ZIP 7 ,r-; i7\,2 0 <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 <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 /> DATE:4 <br />DT-Ma 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: .--Plail (tit cf_ PA p- <br />417- COMMENTS: ftC <br />VbitA_ 406 E.,1116.1) <br />sAA,J0,1 2° 2049 <br />liAlivotfr,QuiNcr, seiL-r,, ,,Ar A,,, .....,(JAI„..„, <br />ACCEPTED BY: Laura EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />V(' 40A <br />EMPLOYEE #: DATE: <br />iMW <br />P E: Date Service Completed (if already completed): SERVICE CODE: 52) <br />Fee Amount: LI.(/.(,i) Amount Paid 4 1.1, , _ Payment Date <br />Payment Type v (Yw6.4- Invoice # Check # Received By: ,_,6 <br />EHD 48-02-025 6,-4* q5,3.1 1 3 ( <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)