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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FA fit <br />. <br />PA DO 7Z L <br />FACILITY <br />1 <br />ID # <br />t ze,5 iois6ic- <br />SERVICE REQUEST # <br />OWNER! OPERATO <br />v CHECK if e ro h( i - )/. 4. BILLING ADDRESS <br /> 7- <br />FAciLiTY NAME <br />SITE ADDRESS, C — tv -pro son .... /, I 72 I H , Street Number <br />A4 <br />Direction <br />3124 A I, )44 1 roson -7-7 <br />Street Name <br />1-10c/ et) 1 <br />City Zip Code <br />HOME 01(MAI,LJ4G ADDRESD(If Different from Site Address) <br />Street Number Street Name PO .' 66 X 19 `I <br />CITY <br />2— <br />. Z • <br />1 lid <br />ZIP <br />to n <br />0 AsLATte le f)...) a <br />PHONE #1 Exr. <br />czoci) P87- 39 g 4, <br />APN # LAND USE APPLICATION # <br />1-k4;1? lc LA 'hi& e <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUE R <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the un(signed property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or-project speci ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my bujies 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 and EDERAL laws. <br />APPLICANT'S SIGNATURE: (fjyJ (-Cd6412.MZ) <br />PROPERTY / BUSINESS OWNER' (7 / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING ARTY, 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 <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 thepame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: H loop c t - t'4 0/16-1/17L-ALivn iwce.--^r,,,! <br />iu COMMENTS: i.",`; `, k., <br />8 <br />2 <br /> 4VJOA <br />8 202, <br /> <br />hz,4L17;ronmfe.N way <br />Depovir,,TAL <br />MEN r <br />ACCEPTED BY: N. 14fe ri- EMPLOYEE #: i / DATE: )2_ //g/2 L92_I <br />ASSIGNED TO: 2—•91' A fr6‘ EMPLOYEE #: ) ' DATE: 12_ /g/2.L72 1 <br />Date Service Completed (if already completed): /2 ' 2 .02_ / SERVICE CODE: 0.0 ( P/E: (l oz. <br />Fee Amount: I 1 /7 <br />It') t_ --- <br />Amount Paid 42 ( Iv ------- Payment Date <br />12-11-21 <br />Received By: y/(72-1 Payment Type (IAALcA,g, Invoice # Check # 1 .!;1, 6 <br />DATE: A2e ,;? / <br />A <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003