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I also certify that I have prepared this application and that the work to be erformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F IERA laws <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <br />DATE: <br />OTHER AUTHORIZED AGENT 51 <br />as -024 -o9 <br />46-6-Air-ro,t Co AJ pe+Cre •"C._ OPERATOR / MANAGER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />14-oPeo\tv mEg____ nzO CA AT( .0 ‘,-) <br />FACILITY ID # SERVICE REQUEST # <br />SROE) S S.. i ---) i <br />OWNER! OPERATOR <br />L STD/F: 1--fo m Es - ELK..11-64)\-i L LC . CHECK if BILLING ADDRESS EJ <br />FACILITY NAME , <br />E Lk Ho/0/ cot i N.n-R.,,, a cu.8 E-67-4rEs w m r- <br />SITE ADDRESS <br />/09 li?) 0 Street Number Direction <br />, t <br />ST. M be, (TL 0 (keLF Street Name Sra c-14:TD xi City <br />9.C2o <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />e- ,4.1Q'1 sTo NE -EN •e 9'0 / .7- <br />Street Number <br />—140 Alki TON ?,0140 5(411-6_-f <br />Street Name <br />CrrY STATE <br />STOCg-r-61 A) CA-- <br />ZIP 2 <br />5 <br />20 2 <br />PHONE #1 EXT. APN # I LAND USE APPLICATION # <br />PHONE #2 FA .(95--f 4 .7.5t EXT. <br />Ii <br />BOS DISTRICT ...2 <br />( e'l <br />LOCATION CODE <br />1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />A U Pt PDO I, g- <S1°1i- lili C • <br />CHECK if BILLING ADDRESS Ea <br />BUSINESS NAME , <br />2_,/ / f 1\4 o F F 4-7 - ,t5LVD i MA-m7 _ca.) CIT. 95733(., <br />PHONE # ,, , 00? )11 63I -6 <br />EXT <br />HOME or MAILING ADDRESS <br />V---/ / ( m 0 F-(-7-71-7- --e.C-VD <br />FAX # <br />Cm( F.-CAI Nil PrKiT STATE ZIP CA <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 />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 />15M ‘41.1i.b TYPE OF SERVICE REQUESTED: ' A.)€_.1..4) AO L /....CM- i4.-#•,..) CV--I-C-r-- RECeN <br />00S COMMENTS: <br />2 2 MI6 kt,i cOUST sANJOAQUiet•TTA1-1,1 <br />1-15ik°1-rm' <br />ACCEPTED BY: C)c e Lie ( e.......4- EMPLOYEE #: OS 2 DATE: (F.724:4j? <br />DATE: ASSIGNED TO: <br /> EMPLOYEE #: c)c{47 <br />Cate Service Completed (if already completed): SERVICE CODE: 52 •- PIE: <br />Fee Amount: 4 1 r .1-coo,e-D Amount Paid -4. Li i3O.00 Payment Date `Fii.„(o cf:1 <br />Payment Type " Invoice # Check # q 1 139 Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)