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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />P'100 * V <br />OWNER / OPERATOR ,-, <br />(.,' • / / l • • A / / e - . V) /7/0 Z S <br />CHECK if BILLING ADDRESS <br />FACiUTY NAME i j <br />/ eiae r'eal/O2 <br />SITE ADDRESS i ILI i ut f.J i 6 f.\, 10— In • A 17fr I Street Umber Direction' \ Street Name 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 (1i"/ — Pa /7e /110/97 YETS <br />(2 61) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION C01:0 <br />errY <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS 0 I <br />BUSINESS NAME <br />/9 6) I L- 82 0 / 4 Cii A <br />PHONE # J2'613t1°641""f4/64(41? <br />(2/)L/ 9 - ,s'", <br />HOME or MAILING ADDRESS po 430x 5 ,.R., FAX # <br />CITY <br />/./'1°Cr)*-- 11177 --7-5---- <br />STATE (i ,57_ 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 or <br />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 ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 <br /> <br />OPERATOR / MANAGER 0 <br /> <br />OTHER AUTHORIZED AGENT 14 <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: - c -0-)L 04-N C (-4 C (C — <br />PAYMENJ <br />COMMENTS: RECEIVED <br />MAY 1 1 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HCAL-T-H-gER4RT-MENT <br />ACCEPTED BY: o I- CO E r / A_ EMPLOYEE #: D 2_ ( DATE: <br />ASSIGNED TO: C czi-2_4e—cLF 1 c, , EMPLOYEE #: t_-_+(( ce7 DATE. 4 (/_s- i <br />Date Service Completed (if already completed): SERVICE CODE: ) 5-- PIE: . ,., 0( .. ( <br />Fee Amount: 3 e 0 tr-L) Amount Paid t ,-3. (-) ,- Payment Date ci L( t 4:=>7 <br />Payment Type .------- Invoice # Check # 51? (IL Received By: <br />/67 <br />4 <br />' SR FORM (Golden 'Rod) EHD 48-02-025 <br />REVISED 11/17/2003