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SAN JOAQI,, COUNTY ENVIRONMENTAL HEALT )EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Sezio &goo- <br />OWNER / OPERATO - <br />/ " CHECK if BILLING ADDRESS <br />IIII C11, II' • 1.11.ftirei f Sri W c i aft <br />FACILITY NAME (A.), <br />r ''' <br />SITE ADDRESS <br />Street Number Direction ' Ne/r/nerc 'b( Street Name _, <br />/C) S C 0 r\ <br />City <br />C62-1 c1 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. APN # <br />7,t, 6 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br />0 , <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />hARA—CrY — \ CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME 1 Li (1Kt, iii /5 pod pc.5. i_e1it <br />n5 <br />PHONEy EXT. <br />(IC. /) CS a - ur' LI3 <br />HOME or MAILING P,DDBESS <br />(77 ou A, i- rc (I q r) <br />FAX # <br />CITY R l' eon STATE (../4 zip 5 526 ( <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 and FE ERAL laws. <br />APPLICANT'S SIGNATURE:/(// f‘l DATE: <br />PROPERTY / BUSINESS OWNEREI OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <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 aiihe same time it is <br />rovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Kft---(7 <br />trkb;:itlif v. El' _c4 r c4-1,-:-(-,dc____Q <br />COMMENTS: <br />g, gra43 1 <br />0'4'k76 <br />844f JO - 6 20 <br />-iitt ixio 1/4 c 11 1 p c-L%-e.- ii k-Nvick, <br />/104,%v794111 ), 41041. <br />A ntCEPTED BY: ,, 2----. i 1 / ' , i <br />EMPLOYEE #: 2 c 7 0 DATE: 2/6 // 4., <br />ASSIGNED TO: li tAL (A) U.4",,,,--I et,-L--, EMPLOYEE #: 5 3 6 .7_ DATE: <br />Date service Completed (if already completed): 'r---- 7_ 2_ SERVICE CODE: P / E: 3 6 z c) <br />Fee ).)4NTlia.unt: 4 z_s-7 Amount Paid ;.2 L) ( 7.), 0 0 Payment Date <br />Payment Type / Invoice # Check # 7 / ) i Received By: 41/4-i---- <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003