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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE <br />SgWS <br />REQUEST # <br />3/1 <br />OWNER / OPERATOR, <br /> <br />ilviCxrca - Q V1C,k CHECK if BILLING ADDRESS <br />FACILITY NAME -pe n A. s ..-cm pi Roy.....1.4„,c, ..\k 5 4-511-0 91-Pi- <br />SITE ADDRESS (.9 2-o <br />Street Number <br />s <br />Direction <br />sot G oi vntruf-0 S) • <br />Street Name Loct ; City <br />oi 52-c-ir <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />3-i- Street Number <br />L_ Iry 5 k_kicx \j (3 v.) Street Name <br />CITY, STATE ZIP <br />1,-- 0 At c 110\ 0/ 9 2_ci 0 <br />PHONE #1 Err. <br />( 2 0?) 9-.C) 3501c, <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />, peitir I 0- IN 1°C CHECK if BILLING ADDRESS <br />BUSINESS NAME yec;\ Rs -kai LA.2,6 6,,,_ - 3 •*- PHONE # •-_. , Err. <br />(2tfi ) 5 to 35-96, <br />HOME or MAILING ADDRESS s,---7 <br />LS lAin i 10 I/0 (Ai) <br />FAX # <br />( ) <br />CITY j - <br />L4 ) 0 I <br />STE ZIP 976 21k) <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: fY flnQAp erin--.0\ DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT 0 <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/thie assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at ttrAiirne it is <br />provided to me or my representative. 0 0An <br />TYPE OF SERVICE REQUESTED:.Tia.;\ 4 AA, % as \,v,s ct,,,A,Tv.- oe, vitt, <br />COMMENTS: alk . 22 eo <br />4944141944, 20 N oofriftcoap _ <br />cfkb.,,,k fir -47 <br />ACCEPTED BY: \I vtomit 0 EMPLOYEE #: DATE: 1 2_ ID t2.0 <br />ASSIGNED TO: S . gl. VIAA, ablry EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 (.0 ( PIE: Roo 2) <br />Fee Amount: 4_\ --i, _ Amount Paii$45:/ z,() Payment Date 72 zO <br />Payment Type Invoice Invoice # Check # n F3.i I/ i /- Recei ed <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod)