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OPERATOR / MANAGER 0 <br />APPLICANT'S SIGNAT <br />PROPERTY! BUSINESS OWNER El <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />SAN J 0 AQUIlv 'OUNTY ENVIRONMENTAL HEALT" DEPARTMENT <br />SERVICE REQUEST — <br />Type of Business or Property FACILITY ID # TA 60 (p// ff <br />SERVICE REQUEST # <br />:-.--• 2 .- <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />NiC, ?__-c-t4 C---A---Tt _M-c-, <br />SITE ADDRESS 360 )00 eTric.„ 16 ‘6,17- vIA Atk.)TZ5CA- C 4 <br />Street Number Direction Street Name City Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) ,c)--(__-_,) <br />Street Number <br />57,4-e eiCret--el) <br />Street Name <br />_TATE r-Di 5 "k >,(E--.-,P'_(_.( a 4____L.,\ c.,..4) <br />PHONE #1 EXT. <br />( - -2--,. D'f (9 c7 2/ <br />APN #LAND <br />)_(,(1)2-0 05- <br />USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 3 LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />(41'S kiler-757ed .--.) <br />CHECK if BILLING ADDRESS , <br />BUSINESS NAME <br />T^ <LC ..i• (C_ Pc-Dcl Fiyi-sir-/)C\ <br />PHoNE# ExT. <br />((,`-7 )6-54 • (-) 3-7 11 <br />HOME Or MAILING ADDRESS <br />i'Ve_Ar-to t;_)(2.,__4_ <br />FAx # <br />(JS) 5-5-6" -03 P5 <br />CITY vv10-7.? STATr A. 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 bu ness as identified on this form. <br />I also certify that I have prepared s application and tha the ork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Sta Ia s, S ATE and FEDE L la s. <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: .E. VAAgT6a, \--,Oc.-)2_ RECEIVED <br />COMMENTS: MAR 1 220°7 <br />SAN JOAQUIN GOUNV <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />EMPLOYEE #: ?„6 yi <br /> <br />- <br />ACCEPTED BY: <br />i <br /> ---i <br />\ - <br />ASSIGNED TO: EMPLOYEE #: (0 (.4(.2 - DATE: <br />Date Service Co 0 • : ed (if already completed): SERVICE CODE: <br />(() ( <br />PIE: <br />Fee Amount: ? 5---- Amount Paid 't, 9s-- Payment Date _.? jc -2 _[ c -7 <br />Payment Type •---- Invoice # Check # I, 1 l4 -2_ _ Received By: ..-7.„-- <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003