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SAN JOAQIJ. COUNTY ENVIRONMENTAL HEALTADEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />41k-,ct. 4 (we-04 I <br />FACILITY ID # <br />FA-VOD 2-CDS— <br />SERVICE REQUEST # <br />912(Z(0 7 0 3o <br />OWNER / OPERATOR b__. k <br />f'cN 4Q10 OlcC OL61 -12 r0 ti•-) e--c # 43Tak.(1 IY \ e-Iikt5 CHECK if BILLINO ADDRESS <br />FACILITY NAME .C. 1 <br />C CkCKe (o \O e c,i - <br />SITE ADDRESS 66(310k <br />Street Number Direction <br />.*--ty).5(C-C oka e co ck r <br />Street Name <br />S-Voc k--k or\ <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />10 1) I (e '1 (4 <br />sfACHEcK if BILLING ADDRESS <br />PHO1 <br />BUSINESS NAME pay.) c 0 si Ny\., ENT V1/4-1C._ NE „ EXT. <br />(70<i) 5 3 7 (0 --6C-) <br />HOME or MAILING ADDRESS ,- <br />5 2-.00 NACk C 't` CV-v" CA <br />FAX #C C c 3 7 <br />Cm(STATE <br />CZ-Ve-- 47 <br />e R. ZIP iIi( S 3007 <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, St. • .; ds, STATE and FDEL laws. <br />OR / MANAGII2 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the LING PARTY, proofof ethorization to sign is required - Till; <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:1;),1,,,- / /21.44,L,Q cid p /44,,,, el---e_cig_ <br />COMMENTS: 4PR 0 4. U <br />Silk 2013 <br />iy cAiiii wiiiiv <br />ocp.„,7,)--4, ' r , Wivt. <br />ACCEPTED BY: yv ,- A.44...(a.e..A. EMPLOYEE #: -2_ c, -7. u DATE: ti f 2_3 / 1 3 <br />ASSIGNED TO: -cd vl 6( oj e y a e. EMPLOYEE #: & -2._ i '..* DATE: ci / 2 ?/ / 3, <br />Date Service Completed (if already cometed): SERVICE CODE: c----2 -1_ PIE: •-t, 0 2_ <br />Fee Amount: Amount Paid # .2,50, OD Payment Date $. _____ <br />Payment Type V Invoice # Check # /5752_ Received By:?I`iti(-------- <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER El OPE <br />DATE: ( <br />1 13 <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003