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SAN JOAQUIIIPOUNTY ENVIRONMENTAL HEALTH APARTMENT <br />SERVICE REQUEST <br />Type of Busine s or Property FACILI,TY ID # <br />A__2) <br />SERVICE REQUEST # <br />'aj-1906:2( <br />OWNER! OPERATOR <br />(f7 <br />CHECK if BILLING ADDRESS 11 <br />FACILITY NAME r- ) <br />C iji/ //fleJ /4/0A- <br />SITE ADDRESS <br />c) 943 / Street Number Direction <br />141 <br />// 5( <br />4 <br />11/ Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm' STATE ZIP <br />PHONE #1 EXT. <br />( doy• ) 3‘.p -80 )--") <br />APN # LI 3 <br />0 '2-`1 - 2-1 0 - QES <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRI; f_CT <br />T <br />LOCATION CODE <br />c f t <br />CONTRACTOR / SERVICE REQUEST OR <br />REQUESTOR e----- ‘ <br />jci-o h,y P.;fitr CHECK if BILLING ADDRESSP <br />BUSINESS NAME <br />c(1:;:jit IV1 PCO / #6..(4et-ej 5 <br />PHONE # EXT. <br />(i)&) 53? - CS00 <br />HONE or MAiuNG ADDASS <br />379C0 )+4 hakc_ goy. <br />Fax# <br />( ) c--37 ._6s--. <br />CITY CErf-,( <br />STATE of ZIP ps-3 0,7 <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 a d F ERAL laws. <br /> <br />DATE: ZeC S APPLICANT'S SIGNATURE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OP RAT R / MANAGER 0 OTHER AUTHORIZED AGEN'ele•"1./xf. <br />If APPLICANT is not the AILLJNG PARTY, 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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: (--c 4=-. A-<-77-/ C P AA cc LT i4- T--7 0 --) - 4--E I (-4-, EN --tr-L-,-- EL <br />T <br />COMMENTS: .) <br />ti <br />001-3Dr-,a1"/ <br />DEC 0 5 2006 <br />SAN JOAQUIN <br />_IRONMENVECOUNTYNTAL rALTH DEPARTMENT <br />ACCEPTED BY: ot_ i u ,s, I 4.A. EMPLOYEE #: 0 3 24 DATE: 1 2...... b 6 <br />ASSIGNED TO: 0 /1_44..ct k.... EMPLOYEE #: 0 4 cin 7 DATE: (2_-( 0 ,k) <br />Date Service Completed (if already completed): SERVICE CODE: 0 Gy PIE: 3 G c).. <br />Fee Amount: it 6y 5, uo Amount Paid Ce\ S ' OD Payment Date \2-( S 1 (56 <br />Payment Type L7--- Invoice # Check # (z. (", c_k. (. Received By: Ws-- <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003