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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />..----- r m/4 TrAfter <br />FACILITY ID # <br />[ _ SERVICE <br />Sr( <br />REQUEST # <br />a7Li 5 <br />OWNER! OPERATOR <br />CHECK if Md n a_ iv( edf 0 6-- BILLING ADDRESS <br />FACILITY NAME 0 114 6 Fr u it <br />SITE <br /> <br />DE SS <br />2det b e r <br />E <br />Direction <br />Hirt, r Ave- <br />Street Name <br />317)ekrtz_5._ 1,... <br />City <br />1c20 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />39% I/ C . Wu) r 71v-12- Street Number Street Name <br />CITY n i <br />Y1) C AttlYk. <br />STATE cf ZIP q s2 0 6 <br />PHONE #1 Exr. <br />( 01) &i 'S '" / 0 sic <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />V1(10 ük V\ eCk M OL- CHECK II BILLING ADDRESS ' <br />BUSINESS NAME A <br />0 M 0 RAO- <br />PHONE # EXT. <br />(..2o )uvc -- i (.1*iSS <br />HOME or MAILING ADDRESS <br />39 /7 é- Alba/ Av 42- <br />FAX # <br />-, <br />( ) <br />CITY Six' 177 yi STATE (":" ZIP qs-Zo s <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 />APPLICANT'S SIGNATURE <br />DATE: <br />PROPERTY! BUSINESS OWNE OPERAT 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 at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment itniation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is providZI <br />my representative. <br />TYPE OF SERVICE REQUESTED: .44 , <br />COMMENTS: <br />8111V JO 1 4 21 <br />1/4414O(Jiiv c 4 riy 0 illittA/044 <br />'1:211/i,71 .7;14 <br />ACCEPTED BY: C....4x cr v.... es c 0 EMPLOYEE #: DATE: <br />ASSIGNED TO: tit\---ee oe..„4. (3 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 PI ,: <br />Fee Amount: Amount: AV 0 0 Amount Pa* / 5:2 , Z.1 Payment Date <br />'? <br />Payment Type 04, /(._ Invoice # Check # Re'cei ed 13: <br />L. <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08 <br />(olltf //9 <br />Title <br />t),