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SAN JOAQUI ",OUNTY ENVIRONMENTAL HEALTH '7PARTMENT <br />SERVICE RE UEST <br />Type of Business or Property FACILITY ID # <br /> rik- 0002-1:71-° <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />C CHECK if BILLING ADDRESS <br />FACIUTY NAME <br />`-'\ eA'AIN r_•• ill, E\ \JAS 1- c)::'!,.-e <br />SITE ADDRESS <br />‘351(.:.) <br />Street Number Direction <br />-1\-)C‘- nNe. 111 A • <br />Street Name <br />S‘,,tv.:... V.% \e, (-\ <br />City <br />CV4-,::; 0 1A <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm( STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />APN * LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT 1 LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />h`S`e' K(L• \L <br />_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE* <br />( I ,...1) 4- A <br />E/CT. <br />HOPAE Or MAILING ADDRESS <br />N - v- 0 r aive_. 1‘4 <br />FAX # <br />(SC) 5_-t S Sis'A 4; <br />CITY n STATE <br />GP% <br />ZIP <br />14-3 L I, <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 FEDERAL laws. <br />DATE: `.-1 1 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / NtAGER 0 OTHER AUTHORIZED AGENT Cc r.t. cLcAtt- <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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: P60 pAy M ENT <br />COMMENTS: RECEIVE" <br />APR A 7 2C3 <br />SAN JOAQUIN COrt.2N1 NmEN.....1-, <br />14& 'Ili <br />ACCEPTED BY: i-k S;Q.-I- EMPLOYEE DATE: <br />-ATE: 4/(-7-7647 ASSIGNED TO:n ( EMPLOYEEf #: 04,41. <br />Date Service Completed (if already completed): SERVICE CODE: 7),--- I E: .:26,2_,.. <br />Fee Amount: 2-10 .'' Amount Paid a 1 0 --- Payment Date LI 1 1/ 0 cit <br />y <br />Payment Type t.„------ Invoice # Check # °.:="t t ( 13 Received By: <br />APPLICANT'S SIGNATURE: 1-s-, <br />EI-ID 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)