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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID it SERVICE REQUEST # <br />,Ro0,777,7 -D <br />OWNER! OPERPITOR <br />V 12-0 -a H 04 1 PcvL )(-- ilinc14 -Iv Lfi ki 1 5 LI-C--- <br />CHECK if BILLING ADDRESS <br />FAcury NAME 1 <br />/ il( <br />SITE ADDRESS <br /> <br />......) Lf k..-1 . .....,.,.........- , -..ectIon ./. A7 Sa &CI <br /> <br />et Name "...-- City Zip Code <br />HOME Or MAILING ADINESS (If Different from Site Address) <br />0 /3C1X -7/ 8 c>"-. Street Number Street Name <br />CITY n _ (or STATE ZIP eq 9 s--,1,7 C (---1-nr-1 <br />PHONE #1 Err. <br />( ) <br />APN # <br />1,0 <br />LAND USE APPLICATION # <br />PHONE #2 #2 EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 7 <br />OYM/ 1- - <br />CHECK if BILLING ADDRESS IZI <br />(r 'e -- <br />BUSINESS NAME ••••"--0 --F ..e ae d ,,,, / fi,/,/s 74,_,,,,s ,s,-7,, PHONE # v,.4.:-, <br />FAX # <br />( ) <br />_.2_...-7-•—e:26-6.5. <br />EXT. <br />HOME or MAILING ADDRESS ",— <br />"1 5' -9-c. /-,-- 17, ine> A,(, <br />CITY clorfr/L STATE CA ZIP 95-2 cor <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 Of <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 nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE 1FEDRAL laws. <br /> DATE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MA ,ØR 0 <br />/1-4-7 <br /> <br />OTHER AUTHORIZED AGENT rd rac <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: S f :11.2) R-C---/ ) 10 d iz__Q_ a --k-- <br />COMMENTS: 8 eip /40 le/ .51-, el <br />ACCEPTED BY: -Gi EMPLOYEE #: DATE: 6" _ y e_f_ / 7 <br />ASSIGNED TO: ia-catrza EMPLOYEE #: DATE: Lei <br />—P1 '17 <br />Date Service Completed (if already completed): SERVICE CODE:----Th ---6 --. .., P/E: (c7 c1_ <br />Fee Amount: g..--7 X ,N_) Amount Paid ? 7 • 0 C) Payment Date 6 _ 1(.4 _ 1 -----7 <br />Payment Type (— V Invoice # Check # ( 7... CA '--7 Received By: 2 <br />APPLICANT'S SIGNATURE: <br />Title <br />au_ /6-cteAk. 04, ckptaiitt SR FORM (Golden Rod) END 48-02-025 <br />07/17/08