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SAN JOAQ6N COUNTY ENVIRONMENTAL HEALTH VEPARTM ENT <br />SERVICE REQUEST <br />Type of Business or Property <br />4i046 2-14- /ti e,4 4- <br />, <br />FACILITY ID # <br />/1400 e <br />SERVICE REQUEST # <br />-s- <br />OWNER! 0 PERATOt- ,.— <br />J (k) ; /644,44,3 CHECK If BILLING ADDRESS <br />FACILITY NAME <br />Vevie_ 17',4 vi 64.,,e_ k lip A-1-7,14 <br />SITE ADDRESS <br />/6-96 Street Number Direction <br />CLALl <br />Street Name <br />y SI-Cr /c...-/c4-1 <br />City <br />95-2-0 7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) P a 0 s?-"--7)( --71.c <--• Street Number , Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />90 ) 4-- 5 2- 6 `:-/ /7•7 <br />APN # <br />i t i-2-'70---t0 2_ LAND USE APPLICATION # <br />PHONE #2 EXT. <br />cY--)2-i--)--4cpc 02 <br />BOS DISTRICT . LOCATION CODE <br />/ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/1/1- k. I / t c keel,. CHECK if BILLING ADORE <br />BUSINESS NAMEA 0 ,.... , 0 /S Pero t <br />e <br />5e-fU( c.2._ Pot <br />) <br />Ex i <br />3 2-7 -2 7S 7 <br />HOME or MA4LING ADDRESS <br />t-'C ON( /6 2 i( <br />FAX # <br />(2(7C ) 33 9' - 2 ` Dry Lect,, 6,4 STATE 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 ENVIRONMEN'l AL 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 ap and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard, and F ERAL <br />/ <br />APPLICANT'S SIGNATURE( <br />PROPERTY / BUSINESS OwN ER 0 <br />)PERATOR / MANAGER <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: 0 0 (..-/S/A-P--__, te---E,-(04 ....z._ ,ic..:4-iv ei-t PEASKINT <br />COMMENTS: . RECEIVED <br />1 JUL -12010 <br />' SAN JOAQUIN couNTY <br />EvemoNMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 0 Li OE / 12-4 EMPLOYEE #: 0 ..3-21 DATE: "7/i /f 0 <br />ASSIGNED TO: E . 4 --,1--7.- 4 EMPLOYEE #: 6,2_42 DATE: 7 / 1.1 I 0 <br />Date Service Completed (if already completed): SERVICE CODE: 52 2-- P I E: ..-g") -2._ <br />Fee Amount: 4 .,) ? e...-_,C. cll.) Amount Paid.3...3 t D. 0D Payment Date cif ,t i co i i t <br />Payment Type Invoice # Check # (eSSicn Received By: <br />DATE: c <br />OTHER AUTHORIZED AGENAD---- <br /> c <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003