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<br />SAN JOAVCOUNTY ENVIRONMENTAL HEA' DEPARTMENT (P
<br />SERVICE REQUEST
<br />Type of Business or
<br />A? LC
<br />Property
<br />:4-11k SC 1406
<br />FACILITY ID # SERVICE REQUEST #
<br />5 W34760
<br />OWNER 1 OPERATOR K ot ja+cea. anAect _ oa t,i-1-.1)e lil. Ois ( c_51 - CHECK if BILLING ADDRESS
<br />FACILITY NAME .
<br />\)./e 64-Cirl Rod c 1 kk 5c k 06 1
<br />ii-b 0 Lo Street Number Direction
<br />SITE ADDRESS
<br />MC Lit 1 Street Naine City Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />C O' Street Name
<br />CITY 1‘ A
<br />I \ j c\AJ -t-t--ee 0- 11 vco
<br />STATE( F ZIP
<br />OT,33(r9
<br />PHONE #1 EXT.
<br />/
<br />Wes-6;1 142...k7cA rkl
<br />LAND USE APPLICATION #
<br />PHONE #2 EXT. • ,
<br />.....
<br />BOS DISTRICT LOCATION CODE
<br />CONTRA 3'er QUESTOR
<br />CHECK if BILLING ADDRESS 0 REQUESTOR
<br /> /
<br />/ I i , \At_ L 0
<br />-.. 1 t t SOAA
<br />BUSINESS NAME 1,1 cuyi_. e 0 6.c Lt d ,---_-,,,,, 1,00(
<br />Di
<br />, 1 4 P(INO:Eilt ) 5 z.z) 7ExT,' .47
<br />HOME or MAILING ADDRESS
<br />R 0 • 6 ox 3-,2__
<br />FAX #
<br />cm )s7/25- - 5-21-i--
<br />CITY ("-k-
<br />STATE (1 i 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 HHALTH 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, SATE and FEDERAL laws.
<br />APPLICANT'S SIGNATURE: 7(5
<br />.
<br />DATE: 1.7 4-6t
<br />PRopERTY / BusiNEss OWNER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT er
<br />U.APPocANT 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 HEALTI I DEPARTMENT as soon as it is available and at the same time it is
<br />rovided to me or my representative.
<br />TYPE OF SERVICE REQUESTED: P ) v--1---7-\ ci,_,_ >ctilf°J2-f-
<br />COMMENTS: , 91'WEIO
<br />? 4:653 PI j coulslv
<br />3oP, 0 0 wils,c,,,,
<br />DATE:,/,, APPROVED BY: 4 0,1\11BOWctIMPAPLOYEE #:
<br />ASSIGNED TO: ae„cfp:
<br />LAI sc,(-7 rrue
<br />EMPLOYEE #: o q co 7 DATE:
<br />Date Service Completed (if already completed): SERVICE CODE: 5'2 P1 E:.-5t6() /
<br />Fee Amount: 53 l_-/ Amount Paid a), s----3 t( ______ Payment Date 7/(9.(4 ( t 3
<br />Payment Type i,., Invoice ii Check 11 3 t,,F (i, ,a,43,--i ) Received By: .--ifj___
<br />END 48-01-025
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<br />
<br />SERVICE REQUEST FORM
<br />REVIFF) G-f-)-02
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