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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />i -ztoYvA, <br />Type of Business or Property <br />co <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR ., 4 i L • , <br />/1/h I' I to x -e / CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS/ /55- <br />1 Street Number irection 4- CLC StifetiNle -&ek•-/-0/1 City <br />q ii-,1-2.1 <br />Zip Code <br />HOME Or MAILING ADDR7 (If _Different from Site Address) <br />T'/ 3 6 sA ex k../c1,4( Street Number Street Name <br />Crry 4 1,ITATE <br />4-he'd') C <br />ZIP <br />qV 470 7 <br />PHONE #1 Err. <br />(F)-9 ? 7 8 0 / or <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />„......SM.,:t_ r-V).<_. CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: 1//7 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Co ,7,5(71-04t '4 ,-) /9110 .1344 <br /> <br />COMMENTS: 014, 'p - boX . W22 ros KS. cf-to 4 - as ,--) c 45 c - iVo &-ioxecr-E. 1,...c....--z, /frE <br />re-cAL'rt..0 •- i. <br /> <br />bri.e , pia-c-,7 7 -.60x a •/— 4 a_ci...._ 81.414;ivoilQ1,21/43 2021 <br />11E,147, &04,41,9ou4,7, <br />ACCEPTED BY: civ..A__ / EMPLOYEE #: 9f 7 DATE: <br />IMP 0 <br />ASSIGNED TO: 'Fr- i' - C EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 6, / PIE: 512 0 2_ <br />Fee Amount: Li* fc- 2— Amount Paid L.. (3 .--- , Payment Date 1112,3 21 <br />Payment Type Ole vp.) Invoice # Check #3 9-02.---4 Received By: atfj-ir <br />DATE: / -_,2) / <br /> <br />END 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003