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SAN JOAQUIN _ JUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Mo121/C— e- PA-r-k <br />FACILITY ID # <br />F A 5 r) <br />SERVICE REQUEST # <br />5 7 c,rot-i -7 7 5 <br />OWNER! OPERATOR <br />Fc e-A% LA lie, 1 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br /> C, <br />,„." <br />004 #7,/ 5cioe, mokk_Ac mc <br />SITE ADDRESS <br />g-35-0 Street Number Direction Ch et-0 <br />Esiocictoyt <br />et--Street Name City <br />9s) 1,C" <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR [., <br />y FL, ge r-- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME ' ( _.4.)51031 1 /06) P14-Str,', :9 <br />PHONE # <br />P 4:// ) 53 7— CSC() <br />EXT. <br />HOME or MAILING ADDRESS <br />54W <br />FAX # <br />CITY STATE C /9 ZIP <153 6 ? <br />BILLING ACKNOWLEDGEMENT: ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAI. 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 />APPLICANT'S SIGNATURE: DATE: 6/0 <br />OTHER AUTHORIZED AGENT,Er <br />I/ APPLICANT is not t e 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. PAY <br />TYPE OF SERVICE REQUESTED: CozoS t_t_i_-7--4 —77 0 /•.j RECEIVED <br />COMMENTS: <br />,JUN 2 0 Zoos <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 6) L t ( l' A- EMPLOYEE #: Y3, 2._ ( DATE: <br />ASSIGNED TO: a 4 ,Z,2-,,t E s c-C) EMPLOYEE #: D q ,--7 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0G, 7 P I E: 36, <br />Fee Amount: -(t. 7 3 0 0 Amount Paid *011n to , tr2) Payment Date <br />Payment Type Type i.,/ Invoice # Check # 4,S-7 -7 Received By: <br />PROPERTY / BUSINESS OWNER': PERATOR / MANAGER 0 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003