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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />N <br />SO b <br /> <br />LP t' S'CA ,k(kk.,, \k1, S tiks <br />FACILITY ID # SERVICE REQUEST # , <br />\ ' RDO -APT7 1 <br />OWNER! OPERATOR <br />----Ck S l't S ) I IOC> CHECK if BILLING ADDRESS <br />FACILITY NAME s ' oirot - <br />Lis. IQ S-004 I-C14/) C tekb bi- <br />SITE ADDRESS t 11 <br />Street Number <br />N) <br />Direction <br />CAL v----6 A-f°‘.. A S-1- <br />Street Name <br />STZ (,ke__TIT)A1 <br />City <br />ciA-Sa01 <br />Zio Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />c5-0 4 GU A S 1A I), cl.'._ g-A Street Number cTO CV, A.) 7.6 Street Name <br />CITY STATE ZIP <br />-c0 (,-fT31,3 c\Tai 2 <br />PHoNE #1 Err. <br />() ?d- D.Sn <br />APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(Q4C-0 C‘g - t, C ar <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />c)Ckkk. \ TkLtrtkkA-Cl_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />-'"c('‘XSCX4A-Ck- <br />PHONE # EXT. <br />( ) V I) LISJ- 3 - a see <br />HOME or MAILING ADDRESS <br />C (St-- <br />FAX # <br />Crry ci5cul.---0k) STATE cf.\- ZIP <br />Ck 5- (VI 2- <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 Of <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this applic ion and that the wo a be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT ii d FEDERAL I <br />A I I Wig ft% 1 1 <br />PROPERTY I BUSINESS OWNER 0 ANAGER 0 OTHER AUTHORIZED AGENT 0 <br />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 isiç to me or <br />my rerjresentative. <br />TYPE TYPE OF SERVICE REQUESTED: (:)()Ct 12 ia,n ate Cr-- pk'S1 0 <br />COMMENTS: <br />i n <br />SAN , <br />I U 20/7 <br />u0,4Qui <br />lieitAl.1,!/RIDA/41 COLJNI, <br />myE-Ao. <br />ACCEPTED BY: 1 ( 114e/mioiciQ fir\-- <br />EMPLOYEE #: DATE: II / /U1 I / '') / <br />ASSIGNED TO: d e , way-ii EMPLOYEE #: DATE: g /10/1 7 <br />PIE: WO Date Service Completed (if already completed): SERVICE CODE: S-C /2") 3 <br />Fee Amount: SI /II --i Amount PaIll$ Li ( 7, a 7) Payment Date <br />Payment Type v"-- Invoice # Check # .2. Received By: <br />APPLICANT'S SIGNATURE: DATE: a-0-016(1 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08