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Type of Business or Property <br />(S)MvO Cone, <br />OWNER / OPERATOR <br />CrArThar Z-- <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />1/45 <br /> FACILITY ID # <br />F-Abboto.b4o0 <br />LOCATION CODE BOS DISTRICT PHONE #2 <br /> <br />EXT. <br />) <br />FACILITY NAME NAME sooLo <br />3'7)5 Qreet ;,1u Dir ,tion LA.)1 sc'r'\ StreC:‘jt Nam'C&A-e City Zip ode <br />SITE ADDRESS OCA .1 (.) n <br />HOME Or Mk. INc, ADDRL3S (It Dills Tent fro:ri Si+e Addres <br />12)1A5 Street Number ()SLtr4e-tr-DName 741-Ve <br /> <br />STATE ZIP <br /> <br />(Jet- OC- 2 0 Ss <br />APN # LAND USE APPLICATION # <br />(2i(1) itos-- 3k1 <br />PHONE <br />Cm( <br />-5ADUC+1--)1\ <br />EXT. <br />Title <br />jte addfess, hereby authorize the release of any and all results, geotechnical data and/or environmental/site ass <br />tu the SAti JOAQUIN COUNTY ENVIRONMENTAL HEAL:1H PARTMEN soon as available and at the same time <br />rns; representative. <br />N. • a 'lir <br /> CEJVE <br />formation <br />AI" or <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />: EQUESTOR ,--- <br />\iCt,r\S I C-Ct A <br />, <br />lair CHECK if BILLING' ADDRESS <br />.:1USINESS NAM 7 <br />e Ovnr-- ,s <br />PHONE # <br />( ) 2:zu -062 7 CI <br />EXT. <br />HOME or IV AP.I lr, ADDRESS <br />1 b Li <br />FAX # <br />crry 5 -n) -Dr\ rZATE ZIP <br />BILLING BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of ..ame, <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 identii ad on this form. <br />also cer-ly lat : have prepared this a,pplivation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />( .7% NTY Ordit,..ince Codes, Standards, TATE and FEDERAL laws. <br />APPLICANTS SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OT 3R AUTHORIZED AGENT 0 <br />It APPLICANT IS not th BIL t /NG PARTY, proof of authorilltion to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: .,'Vhen applicable, l the Owner Of operator of the property located at the above <br />tzklyA <br /> <br />A4,- DATE: <br /> <br />TYPE OF SE ,›VICE REQUESTED: f-130 Vali Ce le j-ivrecAl NOV 0 644 .- <br />COMMENTS: SAN joAQuiN couNiy <br />ENVIHOM HEALTH ENTAL cl-A FirmENT <br />ACCEPTED BY: EMPLOYEE #: DATE: 11/161115- <br />A3SIGNED TO: Je-F-F Naeti EMPLOYEE #: DATE: I Itipilir <br />Date Service Completed (if .1.1ready completed); --, SERVICE COLE: 6c...to co l' P ' E: I log; <br />Fee Amount: 411,0 - or) Amount Paid P iyment Date <br />Payment Type Invoice # Chock # Received !3y: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)