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SAN JOACtuIN COUNTY ENVIRONMENTAL HEALTH OEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />c,-2-aar.'17-7c),--)-- <br />OWNER / OPERATOR ( ' <br />----.),_ l'AA --Qik-K a— <br />CHECK if BILLING ADDRESS <br />FACILITY NAME L f-i- - 10- c_,, --Is , ilne;1(e_eivA_, -P-ood . , —LI ig2.6 <br />SITE ADDRESS <br />9-700 Street Number E Direction *le- C>Hirli et Nam 4A)Ct y 5-loc Vo l rY ci5,905- Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) EE v, 0 et.4& Street Name Street Number Number -Pe <br />STATE CITY tc,L4,k <br />H c4D\ <br />ZIP q 5- 330 <br />PHONE #1 EXT. <br />609) RS 1 - 79c/0 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(U,,45- I -1,27 D <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING ADDRESS REQUEST <br />QRA---_-,r)t, A4 1 C <br />() BuriT N.5AME jy:::c:: lc c itioc lc 67 ri <br />L___{...! .---. / k rr.,,,d , / s7z6... <br />/0 <br />PHONE # (661 ) <br />-9 <br />5/- 7,i <br />0 <br />EXT. <br />HOME or MAILING-ADDRESS i <br />`353" efinci-f AG'e <br />FAX # <br />( ) <br />CITE ci ihr,c, 4,3 STATE C4 ZIP <br />BILLING ACKNdWLEDGEMENT: 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 Of <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 a a that t e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEIERAL Ia S. <br /> <br />/--/77 APPLICANT'S SIGNATURE: <br /> <br />DATE: <br />PROPERTY / BUSINESS OWNERigi OPERATO AGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING roof of authorization to sign is required <br /> <br />Title <br />AUTHORIZATION TO RELEASE INFORMATIO hen applicable, I, the pwner 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 preJ to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: TT_ -_,„--( ,,) ,2 11 1 c i c hi) y e 4-7o, 7 flr-C-47/177-Zz' <br />COMMENTS: ..111z 1 . <br />sAA, 1 20,17 <br />L i c- -t-L ' 1 9 z-- <br />Hpf NVIRGDQUIN CO0 <br />r7 IvE'pAW,v_ rAlt I 4/6-tv 7 <br />c--) ACCEPTED BY: (1 fel EMPLOYEE #: DATE: 7 / ci i 7 <br />ASSIGNED TO: \_\ \A k.. \ 0 1,,,--) EMPLOYEE #: DATE: 7 -/L/- j 7 <br />Date Service Completed -•f already completed): SERVICE CODE: t • (I, / PIE: ) <br />Fee Amount: j c00 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08