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RECEIVED <br />Nr.1,1JL 0 7 2011 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME_ <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />icV--‘1 r <br />-• - - •• ••-•-••••••••_te int_ Firm; I II <br />SEINRIMIMINIVES <br />6yze,062.;_l ?- <br />OWNER/ OPERATOR <br />' CHECK if BILLING ADDRESS <br />Facturif NAME shilt Crro Ap <br />SITE ADDRESS cs- Street Number Direction kr 0 st# street Nen* LW i4 <br />- <br />, OA a /4i, <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Stniet Name <br />Cm, STATE ZIP <br />PHONE #1 EXT. <br />I ) <br />APN # LAND USE APPLICATION # <br />PHONE#2 EXt. <br />I ) <br />BOS DISTRICT LOCATION CODE . <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR --i- <br />L.),M11 @in, r(t---/ y CHECK if BILLING Aoneess ill <br />BUSINESS NAME r / P P IA A Sd 17 <br />Exr. <br />HOmE or MAILING ADDRESS 12 i I _I) r , 4t a ( .4 7,_evo <br />ZIP <br />CITY <br /> VAL raktA,t 0r STATE <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 an EERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPER. ry i Blob; NESS 0 VINCR Et <br />If APPLICANT is not 1 <br />DATE: 7- 7-i( <br />OPRRATOR / MANAGER Aft AusrlioRIZED AGENT Da SE-1/1 )1A her i <br />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: <br />REcEN <br />cctAmEN7s: <br />..e <br />IA A A i <br />.1 full\ r f yv 1 v; 1 n (Ai A 9retf4 lYi il 4 (la/y/1 /44-k (oVec 01. - ( LN 11 1 , s000 p,auT,-, Mil t( tta 1 b iv/ 1/0 4 vtli, bl-ir iiiie 4III hte ri illi/ At St (Oild, <br />ttsP r" <br />vtill‘"corZP ' ' <br />ACCEPTED BY; Le) ,-4.,1 <br />ASSIGNED To: <br />Payment Type Type /1+1t40-g_ Invoice # <br />Check # <br />Amount Paid u-D Payment Date 7/-74( <br />Received <br />Date Service Completed (If already completed): <br />Fee Amount: <br />EMPLOYEE #: q os-T <br />EMPLOYEE'S: (2_ <br />SERVICE CODE: <br />nATE.: 7/7 /Lc t <br />DATE: 7/7 <br />NE; <br />END 48-02-025 <br />REvisEI)¶1 /17/2003 <br />dc-)A,LAN, 0 /411 Fr <br />5R FORM (Golden Rod) <br />Ot71TL9S9T6 017TIL9S9T6:w 0 JJ 22:2T TT02-L0-111f 82-MI7917602T:01 2 /2:.96Pd