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SAN JOAQU_ COUNTY ENVIRONMENTAL HEALT. ,EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />,/ <br />',. ' <br />SERVICE REQUEST # <br />? / <br />( <br />OWNER! OPERATOR <br />Jot Gzr PR optri 1 T3 CHECK if BiLLiNG ADDRESS <br />FACILITY NAME <br />5-CU-IA L., m qt.r <br />SITE ADDRESS 11 c <br />Street Number <br />tv <br />Direction <br />/4 4 tt Ito wl 4vt . <br />Street Name <br />S Tot.X Tors <br />City <br />qS 2.0 3 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CrrY STATE ZIP <br />PHONE #1 Err. <br />( Z DS ) LP I) 3 -- 777w, <br />APN # <br />141- 1)0 - ) k. <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />-1171"1 C4 E i / A r <br />CHECK if BILLING ADDRESSEI <br />BUSINESS NAME ApvAivc co. % <br />szo vANI,fmr4b.iv.) )0010 <br /> PHONE # <br />( zpc ) 41,0 9 - <br />EXT. <br />HOME or MAILING ADDRESS <br />i7 Stv.,..., go A-0 <br />FAX # <br />(t') 4 /14) r7 —1 ) I t <br />Crry STOCK TO.4 STATE C_ Os- ZIP <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 />/eAktN. <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Pi/04i to. r-ik A ....811 cot <br /> <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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: jC/4- 2le'—li'L(Q-0j <br />COMMENTS: <br />ACCEPTED BY: ,vi L_____ 1 EMPLOYEE It: l , , <br />DATE: f_712:7 ---7 <br />ASSIGNED TO: EMPLOYEE #: DATE: /- 7/ 2i7 //7 <br />1E: Date Service Completed (if already completed): SERVICE CODE:P ) <br />Fee Amount: 7 <br />i , f <br />Amount Paid Payment Date <br />Payment Type Invoice # Check # - -. S Zi Received By: <br />APPLICANT'S SIGNATURE: DATE: 4.114 Z- 0 " Zø I <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003