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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNERS OPERATOR / MANAGER 0 <br /> DATE: <br />OTHER AUTHORIZED AGENT 0 <br />I 0 -2 2 - <br />SAN JOAQUIN LOUNTY ENVIRONMENTAL HEALTH APARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />-T) 12 pogi 30 S -race TrocK <br />OWNER! OPERATOR -- <br />N\ 0 M-, V---afac I Qvx.c,N CHECK if BILLING ADDRESS <br />FACILITY NAME "";\ xa <br />VQV1CLS i -Ta9 Uk 1r( a <br />SITE ADDRESS 40 20 <br />Street Number 5 Direction <br />So cv71 04-e7v4-1),----* <br />Street Name <br />t-oot i <br />City <br />015Z-1 a <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />53 'A 5 W CAQ)U..1 I _1•1 - Street Number Street Name <br /> <br />CITY Lo A . STATE <br /> <br />k C. 4A ZIP C152-qp <br />PHONE #1 EXT. <br />(zel ) 31-i q 3 u 5 <br />APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR -5-05.e. /2.6vp4e/t <br />CHECK CHECK i BILLING ADDRESS I <br />BUSINESS NAME 0 Exr. PHONE # <br />(vcc) ) 39-I - 9 3 OS C VI. CA-4 --ra ct 0 c(rca <br />HOME or MAILING ADDRESS <br />5,-i s watt ow 1- iti. <br />FAX # ( ) <br />CITY t_r) a . <br />k. <br />STATE , bt <br />C-11 ZIP q S2-1 0 <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 <br />or 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., STAW and FEDE aws. <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the stye time it is <br />provided to me or my representative. <br />if Tkth4t-vft„-A, <br />TYPE OF SERVICE REQUESTED: ...---OCCA \I e,1,6cto vc.,.)iecch.,0--\". ilek.4 <br />COMMENTS: CC/. . <br />414‘ 12 2049 <br />/tie 1.77. k0A441/41 C <br />/a,477:11v1), <br />4k-41. <br />ACCEPTED BY: \I , VA_ 0 q evi (D EMPLOYEE #: DATE: I 0. .2 2 . 1 q <br />ASSIGNED TO: 1;1A, \MAW EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: CAD k PIE: 11.003 <br />Fee Amount:* \c, i ___ Amount Paid ,-(t 1 2 , Payment Date (016)(9 <br />Payment Type H <br />r` <br />Invoice # Check # Receive By: &fey <br />_44)56 <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003