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TYPE OF SERVICE REQUESTED: u &Lit. 0 tes/Ati-s 6.70„vw-i-A.--rtcp\i/ <br />COMMENTS: vsot 17 ISCuita,gt-77 o.-1 o-F Abox..i ruxic 77 6-(4,44 <br />L.VIAC.Irt C,f,A5C-5 rex_ rporatc, r4.(--- • <br />e-44511-- 7Arl ' 1 -C ) - 76 1 7 ...r° .5 C14-142 (4..TC <br />ACCEPTED BY: 1r /3veVic EMPLOYEE #: DATE: <br />ASSIGNED TO: IV; 61(1/ EMPLOYEE #: DATE: 1 <br />P 1 E:410 1.. Date Service Completed (if already completed): <br />• SERVICE CODE: iL, <br />Fee Amount: I L .0 Amount PalO 6,2, 0 -6 Payment Date - — <br />Payment Type ,Delor:-/' Invoice # Check # / -2....3-0,8•344 q Recei ed By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SiZoot 2P! 3-4- <br />OWNER / OPERATOR erkt <br />X x 4 n Vacc a ri e.a Gt CHECK if BILLING ADDRESS <br />FACILITY NAME, <br />)( -g'C--51 !TEA /(.• <br />SITE ADDRESS 1 --1 t q 0 <br />Street Number I1 /4 / <br />Direction <br />D u iticiPoki <br />Street Name <br />12-0 <br />City ZicPiftym <br />liecE; . <br />HOME or MAILING ADDRESS (If Ditferentom Site Address) 1,,, _I ,\ <br />-73 ciPe9 Al ' 01'11-ccd 0 IC"CIStreet Number Street Name <br />Y L (I e-trz rEitz..._ Le <br />jUL 0 8 <br />PHONE #1 EXT. <br />‘ qCI 7g .-. 67po <br />APN # <br />0q1-(70- as"- <br />'4 LAND USE APPLICATION # &IN jo4 <br />/VVipp C)ti/N CC) Hc- . • .0/vA,,- L7,11:TH PHONE #2 EXT. <br />( ) <br />BOS DISTRICT IF, <br />_r_,',qt/V7' <br />LOCATION COtliARTM <br />47 el <br />CONTRACTOR / SERVICE RE UE .._ <br />REQUESTOR <br />Poi/let-CA 1,i) e,1 Aq.4.14 CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />C Wi / ill di, iy)eev--- PHONE # <br />045! g 31 <br />EXT. <br />HOME or MAILING ADDRESS <br />Z) He, kvir,k Y2.4 FAX # <br />( ) <br />CITY STATE <br />00--- <br />ZIP q s- <br />BILLING ACKNOWLEDGEMENT: 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 an DERAL laws. <br />p -z_ APPLICANT'S SIGNATURE: TE: i <br />PROPERTY / BUSINESS OWNERO OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT jk._ j II <br />If APPLICANT is not the BILLING PARTY, proof of authorization Title <br />AUTHORIZATION <br />sign is required - -- <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 />021 <br />unm, <br />t EA/7- <br />n4) ono! C5 <br />i-t03 - 3 4 2.0