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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />44 C-b 0 rtA-1 d Cotwentefrite, 51are_ <br />FACILITY ID # <br />MOO 1364 <br />SERVICE REQUEST # <br />5 AO 7Y3 Fb <br />OWNER! OPERATOR ..r <br />/14 otA.6 01 5 0 5"" j-oct 1 v 4--D 1 1 ..-._. Cot, K.,47 CHECK if BILLING ADDRESS <br />r FACILITY NAME m <br />C D 0 el-dt, I 5 C °AVC,IICPLE e. 510re <br />SITE ADDRESS 3 -7 .-7 1......r--. <br />Street Number <br />S. <br />Direction <br />C e tA71--er <br />Street Name <br />,Sfock-4-b A <br />City <br />415163 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 5 <br /> 2 z10 - Street Number <br />67 rv ,-/D I A, v‘. Pick ee e a <br />Street Name <br />CITY 5 4_,,,...„>„ STATE ZIP <br />C- A q6 z. 0 -7 <br />PHONE #1 EXT. <br />(;.°Cr) q / 2_7_5 <br />APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />II <br />II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />g e set Bct.rre ft - Prvec-i- Met lAdter— r"" <br />CHECK if BILLING ADORES <br />BUSINESS NAME , <br />V <br />y ' <br />1k5e..1"0 (LC. <br />PHONE # EXT. <br />(551) 2 CPV -2-71 I <br />HOME or MAILING ADDRESS <br />6I(' co. 6 IAA A ve. 5 T] O1 <br />FAx # <br />( ) <br />CITY <br />' <br />.re 1.1. 0 STATE CA ZIP Ct 3 -7 a,/ <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />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 the saffilelle*, is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: .061 .61. Rail (kPci(-- 1,48;c1VE <br />COMMENTS: 5 2 k <br />8.4NJo <br />0 <br /> ovil Ack#A, HE,407.7o,thwcouls7 ozpA...v.,14 <br />--/A447.. <br />ACCEPTED BY: ra (iv 6-'7 4 (hive)/ EMPLOYEE #: DATE: i <br />ASSIGNED TO: 411.1f, a P- lc' kilrch LA 1-Z___ EMPLOYEE #: '5-3 0 ( DATE: 1 _6_1 re <br />Date Service Completed (if already completed): SERVICE CODE: s 2 3 P/ E: j /001 <br />Fee Amount: tq ,:-.,(9‘ b Amount Paid 5/..Z.O.D Payment Date <br />Payment Type Type 2..k._ Invoice # Check # -,-_, (-.4_,' Received By: <br />DATE: / <br />PROPER FY / BUSINESS OWNEREI OPERAR / MA I El OTHER AUTHORIZED AGENT or <br />If APPLIC4\I is not the BILLING P 4RTY, proof of authorization to sign is required <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003