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SAN JOAQL COUNTY ENVIRONMENTAL HEALT EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Apaf-t- hum,- ts <br />FACILITY ID # <br />Anilq9- <br />SERVICE REQUEST # <br />gttcaoll <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAM <br />,,e1.671- tak CarirktOnC <br />SITE ADDRESS <br />Street Number Direction 00 14-11 niVki-f• bir- Street Name <br />(St-t)Ck*A1 <br />City q5-C71D7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP PANE <br />PHONE #1 Exr. <br />( M ) q6a-qq-UD <br />APN # 4fq?E4/ LAND USE APPLICATION # t, <br />AUG 0 <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LiartIvTION CODE 26 d04 EMA CON <br />CONTRACTOR / SERVICE REQUESTOR <br />luiviine,4vAiry <br />uEPAI <br />pa <br />REQUESTOR. v6 Li CL CHECK if BILLING ADDRESS cr' <br />BUSINESE,...1;:til zt6e_tt pot Off 44 <br />'" "," <br />PHONE # <br />(Ol 0173 5 — IM <br />EXT. <br />HOME or MAILING ADDRE,SS <br />c pl i-1-1 i l--1461-w <br />,... , , <br />t-i-C <br />FAx# (q.&, 177 3 - gq,,q <br />crrY /7Cfri14_ (‘ S STATE 04 _ ZIP q5Z;673 <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 />7 <br />APPLICANT'S SIGNATURE: DATE: 24 (Lii <br />PROPERTY! BUSINESS OWNER ID OPERATOR/ MANAGER ID OTHER AUTHORIZED AGENT VI rej3ictaii- <br />If APPLICANT is not the BILLING 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: frU-6-A At4/1"-tr)tir <br />COMMENTS: <br />C 0 i"3 <br />jut. t) 1 20 <br />' lAt "ACT" MO I ENV IRON . i,v.,INII. 1.) E r N itl <br />ACCEPTED BY: V i (k6k9 f)--Ce404/.._ EMPLOYEE #: lp Z.,,1 7.)) DATE: ql, f t 9 <br />ASSIGNED TO:ji bil <br />k, IC41)1"4476L <br />EMPLOYEE #: (0 2,13 DATE: )/‘ (A ) ( 9 <br />Date Service Completed (if already completed): SERVICE COoE: 52,3 P/ : 3(0 2...„ <br />Fee Amount: "-7)61-k Amount Pai0304/ 073 Payment Date <br />Recei ed By: j)----- Payment Type Cy Invoice # Check # 333s--- <br />,9 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)