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11}28/15 03:44PH BZ Service Station Maintenance 916-572-1050 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />OCT 2 8 2015 <br />Typo, of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />PA k)- r%0DW <br />S 20073�.-X 1 <br />OWNER I OPERATOR <br />A <br />CHECK it R.I,I<tJt.Cg <br />FAciLITY NAME <br />�ADDRE3.3 <br />SotADDRESS�}_C}-� <br />Accr-PTEo $Y' <br />EMPLOYEE #; � <br />(TATE: --� <br />�ZC1 <br />AsmoNED TO: „ (0 SC <br />_ <br />D Qxree4 M MbOf <br />DATE: `C <br />`+J WSseal ame <br />CODE: <br />PIE: 0 <br />Fee Amount; Amount Pa' �. jj Payment Data <br />3 9 <br />i <br />HOME or MAILINd ADDRESS (if Different from Site Address) <br />_ <br />C it <br />_... _. �.. <br />Slrael Number <br />----- <br />CITY �' ' STATE <br />Zip <br />PUDE #1 XT. <br />APN #. <br />LARD UBE APPLICATION # <br />_ <br />NIfoNE #2 xT. <br />BOS DISTRICT <br />LOCATION GOD¢ <br />C ON'1'RAC FOR I SEWIC.E REQUESTOR <br />RELIUF.ST[iR <br />f QJ/ //^ CtfECX If Smm Aot =13 <br />BUSIN>t58 NAME�, I^, , ,�# <br />� j- Plwro� <br />DOME or MAILING Rf:s3 fAx # <br />CITY STATE r ,f. ZIP <br />BILLINGi ACKNOWLEQGEMENT: 1, the undersigned property or business owner, operator lir authorized agent of garde. <br />77knowledge that all site andlor project SpOCifiC 1 NWRONMENTAL HEALTW DEPARTMENT hourly Charggs associated with this project or <br />activity will be billed to me or my business as idertti I on this form. <br />I also certify that i have prepared this applic ion a that the work it) be performed will be done in accordance with all SAN JOAOUiN <br />CovNTY Ordinance Codes, Standards, Si'Am d F ERAL IaWS <br />APPLICANT'S SIGNATURE: [3ATE' <br />PROPERTY I BUSINESS OWNER L" M r�PERATDR -AN �M1ER 0 OTtiER AuTmonizeD AGENT 13;*1) i -p �1 <br />If Ar'Pt GANr +s nat MCI 0ret lac PARTY, proof of authorization to sign Is required a 7'rrr� <br />At}THORIZAT.ION TQ. 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 environmentalfsite assessment information <br />to the $AN JOAQUIN COUNTY ENVIRONMENTAL He&Tsi DEPARTMENT as soot/ as it is available and at the $ams time} it 1S Provided to me or <br />my representative. p_ <br />TYPE OF SERVICE REQUESTEO: U 5-F <br />COMMENTS: M <br />i�. C r ..,. <br />`tt� `r<2 <br />o <br />442 <br />Accr-PTEo $Y' <br />EMPLOYEE #; � <br />(TATE: --� <br />�ZC1 <br />AsmoNED TO: „ (0 SC <br />W <br />EMPLOYEE #: <br />DATE: `C <br />Mato Service Completed (if already completed).SEnvice <br />_ <br />CODE: <br />PIE: 0 <br />Fee Amount; Amount Pa' �. jj Payment Data <br />3 9 <br />zy �s i <br />...._�. <br />Payment Type tnvoico # <br />_ <br />C it <br />RECO cd <br />EHO 48.02"025 <br />071t7/08 <br />SR FORM (GoWan Rod) <br />7 <br />