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Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I C E Q V-,LA 1\A C Vibk) <br />FACILITY ID # <br />RA Od2(0 o al- <br />SERVICE REQUEST # <br />S R a 400 49 <br />OWNER / OPERATOR <br />C10 CHECK if <br />00 ille3 MCW .C.2 <br />' BILLING ADDRESS <br />\ FACILITY NAME <br />Id e (AV 'e V) 1 1/41 KE ore (Awl <br />SITE ADDRESS <br />3L \ I i Street Number Direction <br />NI . 0 ELANN)i-s, Ave <br />Street Name <br />SI Oc ( VON) 1 qc)20 4-k <br />City I Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) IA C, c.) Street Number <br />D iWiN0 CT <br />Street Name <br />CITY P STATE c 11, ZIPv-v)m <br />PHONE #1 ExT. <br />(2) 550_c939 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR C\ ) cev...-1„....k._ c.,,,t_i CHECK if BILLING ADDRESs <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAx# <br />( / <br />Cm( STATE ZIP <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 FED laws. <br />APPLICANT'S SIGNATURE: <br />VA. •e-Nor,. ATE: <br />TH ER AUTHORIZED AGENT El PROPERTY / BUSINESS OWNERD OPE <br />If APPLICANT is not the B ING PARTY, proof of aut i rization to sign is required <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 spiel the it is <br />rovided to me or m representative. <br />TYPE OF SERVICE REQUESTED: t 01-' , 'V <br />COMMENTS: N 14 cu SAN jn <br />tv <br />. <br />Ev`i4IQU/N c HEA L <br />ri D E pA Q._ <br />ACCEPTED BY:EMPLOYEE <br />CA-VV.-LA c , <br />#: <br />ASSIGNED TO: 0-r- EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: (12 0" <br />ROM Fee Amount: t to -2._ — Amount Paid /6,2. DC) Payment Date 6, <br />0 A ReCelVed 13y: Payment 'Type invoice # Check # i 4 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />§R FORM (Golden Rod) <br />PRO9•15