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Type of Business or Property Ric 12c 64.1^' <br />re-b-e OwNER • • ERATOR <br />Cyj <br />rc{2.els <br />paci( Avc *KI-1 <br />Sire. am <br />Crry <br />PHONE #1 <br />(5`1) <br />PHONE #2 <br />) <br />SERVICE REQUEST <br />FACILITY ID # <br />FAciLITY NAME <br />SITE ADDRESS 1-viso <br />Streol Number Direct o <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />e 0 <br />5'2- 5 real Numbor <br />no <br />/- _2 <br />Err. APN # <br />Er. <br />A SERVICE REQUEST # <br />CHECK If BILLING ADDRESS 0 <br />city <br />?i1/1 STATEcA StreetNamie <br />P <br />LAND USE APPLICATION # <br />)/OCKroTf — q5207 <br />BP Code <br />BOS DISTRICT LOCATION COOE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />TRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />'+Ztrr DC a Li CHECK If BILL240 ADDRESS <br />BUSINESS NAME <br />. I PHONE # , i o ) C70 (1- (I") s <br />HomE or MAILING ADDR ” <br />/ <br />, 4 paciell <br />GR 5 3 <br />akar( ffil3 F(VC))606(—a-(177 -- --4, r.„— <br />STATE c4 zip 7656 S ! CITY 7--d n---ct ri Le <br />BELLING ACICNOVVLEDGEMENT: 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 JOAQL <br />COUNTY Ordinance Codes, Standards, ST and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY I BUSINESS OWNERO OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT cid yi-Ct <br />If APPLIcANT is not the BILLING PARTY, proof of authorization to sign is required <br /> Tide <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 envirommentaL`site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the me time it is <br />nrnvided to me or my e sentative <br />TYPE OF SERVICE REQUESTED: 101CW CirLeek- <br />RECEIVh <br />COMMENTS: JU N 0 7 2o <br />SAN . in A -..,QUik, ,-, <br />I Ljn-ENVIRON " L.° <br />' 1 ICALTH „ MEN TA <br />'E PARTMi <br />ACCEPTED BY: CLe- EMPLOYEE #: 4°P Ei'S DATE: <br />0e2-1/ <br />DATE: 6 ari ASSIGNED TO: i zi ri.,La EMPLOYEE #: gr • <br />Date Service Completed (Ifai •acklyci —npieted): FEavice CODE: SA3 I E: (C)/ <br />Fee Amount: Lig),) Amount Paid LI-5T6,64r) Payment Date <br />Payment Type Cf_eVirinvoice # Check ft / g2.....6,247 // I Received By: <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />PiQ053(42s-0 <br />(vi(pI2L/ <br />N Ty <br />NT