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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />i <br />FACILITY ID # SERVICE REQUEST # <br />OWNER /OPERATO <br />CHECK if api CV f2 an t JP L 95 BILLING ADDRESS <br />FACILITYrE - <br />(--c_ fl DA SL)QpD(+ Seidl azs ( <br />pITElkDDRESS -15 S Yo Uieet NtAber Direction r-f (n s14'N\ '1Oeet le <br />1 <br />S <br />9.53i? 1 c) IL Ock <br />City (3 Zip Cr.& <br />HOME or MAILING ADD SS (If Different from Site Address) <br />L KC (.- .1-1 Street Number CX-101 SOOt (A) (LC-4 et Name <br />C1334.-- STATE ZIP <br />1 i,. ( CY-AC ( OK) CiT5-36 <br />P.140NE #1 EXT. <br />494 Lo L i - LD gc--{ <br />APN# LAND USE APPLICATION # <br />pRNE #2 _ , EXT. <br />(c(01-6 9108 -4730 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE R_E UESTOR <br />REQUEST - <br /> '.a_. <br />_ <br />CHECK if BILLING ADDRESS il <br />BUSINESS NAME-rke_ <br /> C L-N-DC Ok K...42_ 1 Ck _ C\ <br />P NE # i Err. <br />HOME or MAILING ADDRESS <br />LRO (--4 CAI/1430r) L ( i.,..)0"--\-- <br />Fax # <br />1 <br />CITY T. , fi._ ( ok q .Q.. 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, STATE and FEDERAL laws. <br /> <br />2_ c)ci APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER 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, I, the owner or operator of the property located <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessm <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is p <br />my representative. <br />t the above <br />tion <br />Title <br />TYPE OF SERVICE REQUESTED: Fcnc( 4 eh ici .e__ k ii ye coi-7Ov' ' f <br />SAA, <br />2 <br />,7 496 76 <br />COMMENTS: <br />N) eW 01)3 (Yer tic IV frit:1901/4 c <br />litriti ,,Oilitt-iv,OON; <br />`-'1.,P44 rill& <br />silkivi <br />ACCEPTED BY: 1...Q d r9 EMPLOYEE #: DATE: ,2____._ -aci _ f Co <br />ASSIGNED TO: LA v) hai-LEA EMPLOYEE #: DATE: a_ zpi -J. <br />Date Service Completed (if already completed): SERVICE CODE: C> Lo I PIE: I (0 65 <br />Fee Amount: I---- Amount Paid (). 0 / , Payment Date -2/,,_,) q /, <br />Payment Type ,70 ii, Invoice # Check # Received By:/ya)9-----, <br />EHD 48-02-025 <br />07/17/08 SR FORM (Golden Rod)