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0a8- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAk eMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A pA kr rort1 /41 Ts <br />FACILITY ID # ---, SERVICE REQUESTA <br />'Dr_ b67a951) plet)4t70185 <br />OWNER! OPERATOR <br />T 'Bs t-lbwiEs CHECK If BILLING ADDRESS <br />FACILITY NAME <br />PO& 6,102,0Fnl A PARTintrns <br />SITE ADDRESS ito G3 <br />Street Number <br />Al <br />Direction <br />R I pofti Lo <br />Street Name <br />Zpon <br />City <br />5536 -3 <br />ZID Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE 411 EXT. <br />t ) <br />APN # <br />2(01 β€” 0 30 - 32 <br />LAND USE APPLICATION At <br />PHONE #2 Exr. <br />( ) <br />BOS DisTamT4 <br />C90 - <br />LOCATION CODE <br />(9 C, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />xia t_. s I FOX <br />CHECK if BILLING ADDRESS 0- <br />BUSINESS NAME β€ž.. <br />_.t..jAnd <br />/ <br />POOL 3 <br />PHONE # <br />(269 ) <br />EXT. <br />5%13 - Fib9S- <br />HOME or MAILING ADDRESS .-.% <br />V.0 . 80)( 2295 (arcsI 611 OS302 <br />FAX # <br />( ) <br />CITY CE Ree. <br />/ <br />STATE c-A ZIP is-36 '7 <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 OE <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this a licallon and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TA E and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 3 - 3 - <br /> <br />PROPERTY / BUSINESS OWNER 0 OPE OR / MANAGER 0 OTHER AUTHORIZED AGENT El 63.474'4 c 7V,e <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 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 provide* me o <br />my representative. 41 <br />TYPE OF SERVICE REQUESTED: 4 (u 12,--0 / A Plan 0 hdc rreopn <br />COMMENTS: 4Pi? 0 <br />8 4 euf e lei% AtitittoN bv co <br />7'1 DepAbevektiL4 <br />ACCEPTED BY: Sficili EMPLOYEE #: DATE: 4/._ k _ ns, <br />ASSIGNED TO: 4 1, a ...atzett EMPLOYEE #: DATE: c././(5, .7S 4ga-ea _...? <br />Date Service Completed (if already completed)': SERVICE CODE: oc. PIE: /4)0/ <br />Fee Amount: (00 Rod Amount Paid (2/57: 06 Payment Date <br />Payment Type Type e β€žIt_ Invoice # Check # 43-3o Recei(red By: /1 <br />EHD 48-02-025 <br /> -sit/(g ReAA-C .24-> 4β€” e-tkaacd , eiraSet.itd-%e., <br />SR FORM (Golden Rod) <br />07/17/08 <br />0 <br />18