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I also certify that I have prepared this appli atio <br />COUNTY Ordinance Codes, S s, STAT <br />at the work to be performed will be done in accordance with all SAN JOAQUIN <br />I s <br />DATE: t>i ZO <br />PERATOR / MANAGE 0 OTHER AUTHORIZED AGENT "7:47Lkyk) <br />ILLING PARTY roo if authorization to sign is required Title <br />APPLICANT'S SIGNATU <br />PROPERTY! BUSINESS OWNER <br />If APPLICANT is no <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />SR <br />SERVICE REQUEST # <br />OVUM i5L11171-k-i s T TEtetR__E__ <br />OWNER / OPERATOR <br />likr<Ps-BIAM41VOt\WAsivillt.tE CHECK if BILLING AD DRESSAr <br />FACILITY <br />PH <br />NA&(.3 -R. oixAi-tvosisittiraf\t/c 15UbCkkii-91\itAXit' <br />t <br />SITE ADDRESS <br />1,2 G9 liCknalt3ri DZI Street Name s'-r6c0-6 Ci Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />-F 013 CD \ 09-kg Street Number Street Name <br />CITY STATE <br />..(Z;2--C-kttrif3 CM- IX <br />q P.2, ct)q <br />PHONE #1 EXT. AP NI; 6e- 2city... „ <br />o6 <br />LAND USE APPLICATION # <br />._,c..)002,‘,G <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />2019 <br />ouiv 7), <br />rAt <br />tiENT <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />'t.ii I Kt?''VLOg CHECK if BILLING ADIRe <br />BUSINESS NAME t- t IN) E- _ 2 D_ 3(t- t ( <br />PHONE # <br />) <br />Jut. 1 <br />HOME or MAILING ADDRESS FAX # SAN Jo <br />;?1°1-)/No <br />re\ STATE <br />lipit oN,,A.c.Iv <br />ZI F9, 5 7./ Pdtif?7. '175 CITY c_. K 1.tj <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 Or <br />activity will be billed to me or my business as identified on this form. <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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED:___c61tj "K'tiji- P21 17 //.1-4. Ze, ace ' P-Lti iNK-) <br />COMMENTS: /mt.( 6._ <br />ACCEPTED BY: EMPLOYEE #: Oi / k„--- DATE:o 0 r <br />ASSIGNED TO: EMPLOYEE #: i -)Z7 z <br />Date Service Completed (if already completed): SERVICE CODE: Se-2...3 <br />DATE7(/ i (9 <br />PI E 0 Z. <br />Fee Amount: <br />Y' 6°5/ Amount Pai t Og j D Payment Date 7//j7 <br />Payment Type (/ Invoice # Check # 133 Received By:dg <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08