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tr.41 •F, *'\r. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Stlave_ ice 0/Acic <br />FACILITY ID # [RVICE REQUEST # <br />2-- <br />OWNER / OPERATOR Sim/set 3Weet / itry r-) bUOn g - CHECK if BILLING ADDRESS <br />FACILITY NAME Sufal SuMS <br />SITE ADDRESS 14 qco, <br />Street NumberNumber Direction <br />k) 1-/ItY1 2, <br />Street Name /0/ City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 241 <br />Street Number <br />Wil/t3perth C <br />Street Na e <br />CITY L,OD r STATE 041 <br />Zip <br />PHONE #1 Exr. <br />(2c9 41 g 00S-4 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR i Ittieri ptg,4 ,„ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Suine7 Ja9- OIS <br />PHONE # _........ <br />C7/ <br />EXT. <br />HOME or MAILING ADDRESS 2,4 A. <br />iih- IA) C3't <br />FAX # <br />( ) <br />CITY koDi efk qcazi, STATE eh ZIpqc-I42 <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 Of <br />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: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: NA,M I fi-Dd Goroa RafM71 iiigi974 <br />COMMENTS: c y <br />414y <br />aiiii i a , <br />11441/%4, IN co <br />771 ,op4147-4 4/04 <br />ACCEPTED BY: <br />Ora <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: at, i P / E: itio,0,-- <br />Fee Amount: <br />( <br />S, 15 00 Amount Paid / Payment Date <br />/ ) <br />Payment Type 1 Invoice # Check # Received By: <br />1/ <br /> <br />DATE: <br /> <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)