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- s • V V U yuulity <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID 4 <br />-ak2124-ZikP <br />SERVICE REQUEST <br />g.00_k <br /># <br />isi <br />OWNER I OPERATOR <br />209- 830 )580 FAN 20c) j/(czr w n AnwhsD Et <br />FACILMY NAME la.) ("-It-e.Y-S•N -One- • R pa, b4 ril ern. 4 - yoirtz 3 <br />SitF_ADURESS 0 s i <br />Stant NUrag to Ole•aMfon <br />w . Yr); 014 le -Cieil Vc-- <br />SReet Name <br />I 77 2 ei cc;r17 VS .3 7 7 <br />2Ia Coda <br />HOME Of MAD* ADcrees Jr Different from Via Address) <br />31.feel Nova sows mile <br />CITY SrArE ZIP <br />PHONE #1 arr. <br />( ) <br />AIM* Wm Use APPucavnots X <br />Piton #2 Ur. <br />( I -- -- <br />DOS ras-retcr 1 LocATioN Coot <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUE5TOR <br />Geke.:Yr&k) <br />CHSCK IF a WioG ADDRESS <br />PPM # <br />( 1/ <br />HOW or MAILING ADDRESS 79 o 1 1 4 41, kt,ee_ <br />FAX # <br />( )1- 9/6 T/€1 7&3& <br />cm" 501-C Ni,--A/wv en VD , e A STATE eil ZLF Ks, z C <br />BILLING. ACKNO'WLIEDGEMENT I, the Ludersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site Etrid(or project specific ENVIROI.DZINTAL 2EALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me cr my business as idetti:fie4 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 SAu JOAQUIN <br />COUNT? Ordinance Codes, Standards, STATF, and FEDERAL lavr. <br />APPLICANT'S SIGNATURE: <br />I PROPRIETY / BUSCNEsS OwrD OPERATOR / MANAGER OTHER Aureole/ED <br />I,f.=PPL'CANT is not the BILLIV PARTflt 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 Ritthirize the release of any and all results, geotecturical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENIIIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representive. <br />TYPE OF SERVICE REQUESTED: re°1.• - /6 la:47k, <br />, Commas: I e. c,,,,e ha. iii• irt \ Q e,..se se".42 k es 0 LS T. bn_ C.. , Am 0 vt ._)e..4-s-7-r-.3 "3 /4 sie ,.-- <br />; fh• 5 ,1=1 / ge.,/45,14.,-5/4 '. CV h %/e-/ hiefietce- Cferv rite ;l 5/my/gess v .-e <br />-\----e-k-- sea, A i m 4; 4/./ 0 Aii..y <br />AcceperEo By: <br /> <br />EMPLLYEE fk DATE: <br />ASSiGNED 70: frA—M EMPLOYEE fit DA-re: <br />Date Service Completed (if already completed): <br /> <br />! Z_ f <br /> <br />SERVICE CODE E: P 0 2, <br />Fee Amount: 0 Amourt Paid Paymerrt Date , 7_, Lk z_ <br />Payment Type c, Invoice # Check 0 t -_--z) k_t(-) Received By: <br />EHD 48-02-025 <br />REVISED 11 /172003 <br />J,! <br />IREENE4VOT39,co, <br />AUG 24 2012 <br />DATE: :11( .641/1 2- <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />C: Su 5 4.--K•vt. /6 eN-Vr-rkk,i)co01...S <br /> HEALER DEPARTMENT