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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # AERVICE REQUEST # <br />S W 00S522q- <br />OWNER / OPERATOR <br />CHECK if ..z_fis RA- , iv R E BILLING ADDRESS Er <br />FACILITY NAME <br />SITE ADDRESS /'3 3 e <br />Street Number Number <br />,E <br />Direction <br />,-/)./7--- //2/LE-I 20,4, 5, <br />Street Name <br />5-roc Jr <br />City Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) 90.2e <br />Street Number <br />,FA 5 r- IAIA7RI--(9 . RD _ <br />Street Name <br />CITY , STAT, ZIP <br />PHONE #1 #1 EXT. <br />(°1°I) c2 30 — 3314 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT :_.1 LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR -• <br />t.ON /1'(.5ikrel <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME (2i <br /> t5A/)/ ON 5 6a-f/A117 <br />i PHONE # EXT. <br />HOME or MAILIN D DaRESA <br />37/ 4- <br />FAX # <br />( ) <br />CITY .--'------ <br />/ 6(P t-0 ck STATE ek ZIP 9 6-3 Is. i , <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 ap cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, AT and F L laws. <br />ALg <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 <br />If APPLICANT is not the BILLING PARTY, proof of a orization 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 envirorunental/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: obt,r5 pe,41(//v, rgAre- /4/77 44 vavi /fEelt2er - _-)(7&.-1>i rEO iz43:14-94 <br />COMMENTS: 0 c h ec lc , IriE•A ..._ 1 <br />k.Qt, <br />ir n <br />sky jc,,, co <br />N E.411111P4iIN C Q41. 0414,_ Ou, <br />ACCEPTED BY: ..."""-L77 Z /.... _ EMPLOYEE #: <br />ti <br /> itto filz-A, DATE: 4/F1 <br />ASSIGNED TO: F G EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ..,3 3 P I E: Li ) o i <br />Fee Amount: 4 9 <--(:, t; x i. , c) 14 6'a f Amou nt Paid s-ii .o.6...)6.) Payment Date <br />Payment Type Invoice # Check # ,_.?..',--r ,-.) Received By: <br />APPLICANT'S SIGNATURE: DATE: 673A <br />THER AUTHORIZED AGENT 12/ <br />El-ID 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003