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BUSINESS NAME <br />STATE Off <br />CONTRACTOR / SERVICE REQUESTOR <br />(7F. <br />Etib5 /LC 44- (-; Thri <br />FAX # <br />) <br />CITY <br />REQUESTOR <br />HOME Or MAILING ADDRESS Li Li ro-7,7A 6-er i <br />ZIP 95' <br />PaE4 zq <br />CHECK if DiLLING ADDRESS Er <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Prope y <br />ni go A' <br />FACILITY ID # SERVICE REQUEST # <br />-'I: /r-1 ' <br />OWNER! OPERATOR - <br />CHECK If DiLLING ADDRESS IJ <br />FACILITY NAME Weloefs q ---)vx__ pl <br />SITE ADDRESS bri 5c) <br />Street Number Direction <br />Pax4-ri-c- 4‘),2-. <br />Street Name <br />..toc,i,--4e..,t,-L• <br />City <br />cis-e-c, 7-- <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) LI (4(4,0 <br />Street Number <br />• 11)--ca,i r-, <br />Street Name <br />CITY <br />'FC)&tr—kCV STATE c ZIP 9c-206 <br />PHONE #1 Exr. APN # <br />(ZOCI) 2C1 i --- q <br />LAND USE APPLICATION # <br />. P H2ON 9.2 <br />(l) E % 16 ,... I. ..7.1 7, EXT. <br />ZeP'1 <br />DOS DISTRICT 1 LOCATION ATION CODE <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 pplication and that the work t e perfer sod will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar SrTE and FEDERAL JAWS. <br /> DATE <br />PROPERTY / BUSINESS OWNER UK OPERATOR / MANAG El OTHER A UT ORIZED AGENATTEll <br />If APPLIcANT is not the Bllapi-G PARTY, proof of authorization to sign is required <br />APPLICkNIT'S SIGNATURE: <br />AUTHORIZATION TO RELEASE, INFORMATION: When applicable, I, the owner or operator of the property locatO the <br />above site address, hereby authorize the release of any .and all results, geotechnical data and/or environmental/site <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the son <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />. <br />Ni2kA) - 0,- ,,,_62_ <br />COMMENTS:&141,/'061° 4 1,,e, e lik"-(-- (:)-/- ne v <br />'',14,7.4441 <br />ACCEPTED BY: COL......{61/4--e.-S- 1-C. EMPLOYEE #: DATE: CT_ S— ,..._ ( (S <br />ASSIGNED TO: 0 \A V c-xl.,- -iCI EMPLOYEE*: DATE:/ — _ ( k <br />Date Service Completed (if already completed): SERVICE CODE: 06.,./ 1 ( E: _13 <br />Fee Amount: 5--. , Amount Paid,/ A302. )O Payment Date q/s--// y•-• <br />Payment Type <br />> <br />; 64.___ Invoice # ChecIC # 4 ..4e ?---.2,S4jes-0)Recerved <br />SR FORM (Golden Rod) EHD 45-02-025 <br />REVISED 11/17/2003