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07/1 3/2011 WED 10:03 FAX 2098301581 Waterstone Apartments <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE RE UEST <br />Type of Business or Property <br />C47,- <br />FACILITY ID # SERVICE REQUEST # <br />0 W N E 1 'OPE ATOR 1 <br />v o / SI5 A EJ CHECK if BILUNG ADDRESS <br />FACILITY AN IE ,„,. I <br /> W akteN('j41)141::- IWPA\-PCV •0 <br />SITE ADDRpS <br />11S 1 Street Number E1AL2n <br />\47)\ <br />/41 Ilktre(41ame <br />-T-rovci <br />City <br />95377 <br />Zia Code <br />HOME Or MAILING ADDRESS Of Different from Site Address) <br />Street Number Street Name <br />CrrY STATE ZIP <br />PHONE #1 Err. <br />2ol cS30- I W) <br />AP N # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UEST <br />REQUESTOR <br />1 1 \ A I <br />_ <br />CHECK if BILLING ADDRESS El <br />BUSINESS NAME L.L. \ <br />IQ <br />‘ <br />,...8.E.0. <br />P*) 2-30D '-412 <br />HOME or MAILING ADDRESS-I:125 ç '1 <br />Cu QV AC1) <br />F62 : 6,7 ....D3e, <br />CITY Or\ <br />U2-4 k) <br />7 ZIP ) STATE 49, <br />BILLING ACKNOWLEDGEMENT: I the undersigned property or business owner, operator or,..21Ltborberi ring 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 ork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards. STATE and F o RAL I S. <br />APPLICANT'S SIGNATURE: DATE' <br />PROPERTY / BUSINESS OWNER El ,'ERATe RI MANAGER El OTHER AUTHORIZED A GEN <br />[APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AU HORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: OOP PAY tiltHI <br />RECENED COMMENTS: <br />DATE: <br />DATE: <br />JUL 20 2" <br />,,,,„aupi coorY <br />ENvIRONIA ENTAI- <br />140,1-Th °E"j1 1 ' <br />.77 ,,,,v „ <br />',if e a <br />ACCEPTED BY: b ..4,ef rirr EMPLOYEE #: 494 1 <br />ASSIGNED TO: ketiteitelveroV EMPLOYEE #: C,474 3 <br />Date Service Completed (if already completed): SERVICE CODE: cpa— PIE: <br />Fee Amount: Amount: 41100 Amount Paid 15.....4 if , 0-D Payment Date <br />Payment TypePit\k& Invoice # <br />— <br />Check # Received By: <br />li <br />1) od) <br />A 11)? 16g EHD 48-02-025 <br />REVISED 11/17/2003