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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />?V-00VCil .02 '.\ i C \-C <br />FACILITY ID # <br />• 60 -2-C G,Cy <br />SERVICE REQUEST # <br />17-- ROC) 7 31 7 --. <br />OWNER / OPERATOR <br />?- CHECK if - 0 \A \ BILLING ADDRESS 11 <br />FACILITY NAME 6 ‘ A b\20cc Q -1:-.1- X A( /:-/ 5 / <br />SITE ADDRESS 7 iT--77//e, 6--2-- <br />.--- z----- Street Number L <br /> <br />CA)/ <br />Direction <br />Z-ektc I q i -2 ,/,' <br />Str ?.et IT me ( <br />} Get :7 d lc' <br />,./ Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br /> L1.i_21.-:, r a i.,. / Street Number Street Name <br />CITY STATE ZIP <br />EXT. PHONE #1 <br />7/6 ) 77, <br />APN # LAND USE APPLICATION # <br />1 <br />PHONE #2 EXT. <br />(9A 7 7K 5---- 'Z- <br />BOS DISTRICT LOcATInN CoDE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTC R <br />,..4f(/-/--y2 k:HECK if BILLING ADDRESS n <br />BUSINESS NAME /-"= _.,--- <br />/9---47..X c--?.--> C7V) <br />PHONE # <br />775 <br />HOME or or MAILING ARDRESS <br />t‘..., -4%-' • <br />FAX # <br />CITY 5 ,x,,,,,/.. fr.„,,,e,r _zz-__, 6...--;„4- STATE 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE3110 FEDERAL laws. <br />APPLICANTS SIGNATURE: <br />DATE: <br />PROrERTY / 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, 1, 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 provipiAto me Of <br />my representative. /e <br />7' <br />Title <br />TYPE OF SERVICE REQUESTED: Velhil-/ -V44 -'c4JoYl. <br />r•rt--" ..._ / c 4 <br />COMMENTS:s jig /1/ 0 5 <br />titlfr 4 QU <br />lit'lt riffiQu1/4 C <br />— Otp'01,q94/4 zio,47/.. <br />ACCEPTED BY: EMPLOYEE #: DATE: V 91 l_te <br />ASSIGNED TO: at 01 C EMPLOYEE #: DATE: 10 1 iJo <br />Date Service Completed (i already completed): SERVICE CODE: , P E: l i.,••" <br />_ <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)