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R/ MANA <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />r- Ciro-M sYthp — 9esiovu rowt-t— 4 <br />FACILITY ID # <br />(0) AS-11 <br />SERVICE REQUEST # <br />SPXYVVP <br />OWNER! OPERATOR <br />L()Air a &arc! q CHECK if BiLLING ADDRESS <br />FACILITY NAME --r- <br />\ f--7 Ora ODWet <br />SITE ADDRESS g(2., <br />Street Number <br />/.1 <br />Direction <br />loci-rimI fey sT _ <br />Street Name <br />stuClitinn <br />City <br />Wo3 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />0 LH Street Number <br />tiOr&ekall 1 Da <br />Street Name <br />- <br />MOM n <br />STATE <br />aft <br />ZIP <br />gra <br />CITY <br />PHONE #1 En. PHONE <br />(2:011 ) LI 30 -069 22 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />I ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ) <br />Lam( a Garcict 4 e-i-roLin CHECK if BILLING ADDRESS <br />BUSINESS NAME -- <br />l'Cnial C011---te, <br />PHONE # <br />I 1144 ) CI 5 0 <br />Err. <br />06 q 3 <br />HOME or MAILING ADDRESS <br />()Liq Horst-011k Pic.( <br />FAX # <br />) <br />CITY gl(MD11 STA,* ZIP 67pt y <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, ATE a EDERAL laws. <br /> <br />DATE: 13 120 <br /> <br />OTHER AUTHORIZED AGENT 0 <br />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 theme time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:- '*c '4t III . ifrii4 <br />COMMENTS: k 1 4140.,„ a 0 <br />ii evi o e0e0 <br />414 fib 0/40 e \pang e, sof OtAhlosiiiP No kt, coo Ex, ekt 4,4, 44,•ils <br />ACCEPTED BY: Latiti0(C, EMPLOYEE #: ? 0 DATE: ) I i 1"1.,/ / 70 <br />ASSIGNED TO: Mari ba „pl 53 EMPLOYEE #: LP ( DATE: 1 I I I 3 i2„..0 <br />Date Service Completed (if already completed): SERVICE CODE: 6101 P E: i <br />p <br />02._ <br />Fee Amount(, IS—'2, (J()Amount PaidAS),OD Payment Date <br />Payment Type ey,.._ Invoice # Check # 377 <br />. <br />Received <br />/ <br />By:7171 <br />APPLICANT'S SIGNATURE: <br />ROPERTY / BUSINESS OWNER 0, <br />If APPLICANT is not the LLIN proof of authorization to sign is required <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003