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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTAPEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />L-1R•C)-71-1--(05 <br />OWNER! OPERATOR <br />CHECK if h C rc IV (iv) a c- e_ C ( e c-,vv\ BILLING AD DRESS 0 <br />FACILITY NAME __ <br />7-)1AA C C-ck icC eIlte r- 1J. <br />SITE ADDRESS ( 5 5 %t, Street Number E- Direction <br />c_c‘. v Pc , r <br />Street Name Zip Cndo <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />( 101 ) 12:)._ 10i \ <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR , <br />GlU id.,(t/ Si l'N 1/\ CHECK if BILLING ADDRESS <br />BUSINESS NAME v A 0 , 1 <br /> <br />v Kriit\k) L 7c e C r e Avl- PHONE # <br />(,,f)ci 221-- - q 01— \ <br />EXT. <br />HOME or MAILING ADDRESS <br />S 1 41) (Plien0Ye k)C‘-(-3 <br />FAx # <br />( ) <br />CrrY (=A_ 0 t-0.\,\ STATE C 7)- 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, SATE and EDE (raws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El <br />DATE: 01/ °.)/1 6 <br />OTHER AUTHORIZED AGENT 0 <br /> <br />OPERATOR! MANAGER <br /> <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 prov4t4toine or <br />z i ;if my representative. <br />TYPE OF SERVICE REQUESTED: Fizm c„.-1.c....1_1-..c>1-i 4-1,-... ,..:4,, <br />t ' ' <br />7 t loq <br />COMMENTS: 1'' Y ' 0 8 20 <br />SAN .,, ,,,„ ,.., -ii „ -,., cot .,EALTH 0,frviE-Nr <br />cPAR T,,,,ill . ,,,i,4 <br />ACCEPTED BY: LE) <br />MP'? <br />EMPLOYEE #: DATE: 3/1 I <br />ASSIGNED TO: fr14.4410ed Tit foy-,AitAA-- I EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: tc,„03 <br />Fee Amount: 41 30- .t) Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />7. <br />16' <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)