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PAV )10)-3--s-,-,Q 3 r EXT. <br />BUSINESS NAME $7 <br />..e411P <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Oio 10 Ai: ti \CHECK If BILLING ADDRESS <br />HOME Of MAILIN?DDRESS <br />V) 1S- '• 1-\vc A <br />FAx # <br />( ) <br />CITY STATE 014) ZIP ji 4:=2) <br />APPLICANT'S SIGNATURE: DATE: 511cAY, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />1.\\ Al3 <br />SERVICE REQUEST,ft_ ) <br />5 ii0o7 ci ) <br />OWNER OPERATO • CHECK If <br />b 11'..A ki P BILLING ADDRESS <br />FACILITY NAME <br />ime,c 9, g1-0-) <br />SITE ADDRESS <br />IA 1 II • • <br />1\1 <br />. .. <br />lk, / leC Kbt .„? vo <br />HOME or MAILINO4DDRE4 SS (If DI <br />C, Cat s va ,-11S <br />tereirit km Site Address) <br />Kesto 4 Stiqet Numbpr <br />/V <br />Streit Norm <br />STATE CITY V464, 0),--v,. <br />z w b.4 70 <br />PHONE #1 Er. <br />1 3 -ca3T <br />APN # <br />2 0-15c <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />CO 5 <br />LOCATION CODE <br />0 32) <br />,BILLING ACKNO DGEMENT: 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 appli anon and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar , TE.and FEDERAL laws. <br />PROPERTY / BUSINESS OWNEJLI OPERATOR / MANAGER El OTHER AUTHORIZED AGENT El <br />If APPLICANT is not the gILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RE • SE 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 samSime it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: r4 <br />COMMENTS: <br />- <br />414 y 2 5 , <br />Sky do co, <br />ki 440Qumicol, ....4 47.,_, __ /v4i, _4141 <br />'7 D P.,1;.ir;14 <br />'4/41 <br />ACCEPTED BY: 6 0 CIA.Alfet( <br />, , <br />EMPLOYEE #: --2:-.) tb6A,./ DATE: (... . ....- c.76 <br />ASSIGNED TO: t‘, ir-,, \r-\c.A._r e 4.-, EMPLOYEE #: ".4 sk6 9 DATE: <br />Date Service Completed (If already completed): SERVICE CODE: 06 I PIE: <br />Fee Amount: \ s-2_,— Amount Paid /5-42. ot, <br />----' , <br />Payment Date 5/221/y <br />' Payment Ty*_. V/‘...-- <br />_ Invoice # 1 Chydk #6514: # AI ios--3 ,-- Received By: 7y4 , _ <br />SR FORM (Golden Rod) E H D 48-02-025 <br />REVISED 11/17/2003