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41. SAN JOAPCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />LcAct4c_Kv-mutA 1,,I(A)3 c_ovcd-_. <br />FACILITY ID # SERVICE REQUEST # <br />5, OWNER./ OpERATOR „ <br />CHECK if BILLING ADDRESS <br />FArn ITV AIAMF . <br />CO cili‘An,?) I a_ Stnc,vv <br />1 Direction 1 C.___fW <br />'CLArl_p_s <br />SITE IADDRESS <br />-r3 6—Cli 4..A1 Street Number C-1 1\ttre--etVim'e C\\ 6+8r-id-W,1 94-;z15- ip Cod e <br />HOME or MAILING ADDPFSS (If Different from Site Address) <br /> 2 (.0 1---r 44 Street Number Street Name <br />Crry STATE ZIP <br />52Z(0 <br />PHONE #1 EXT. <br />(20() 2'-3 <br />APN # <br />C-91(204-17_ <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />)...."\E‘r\STO‘R ivIwrAk 18 a elevvve____2_ CHECK if BILLING ADDRESSTI <br />tsgeS isv\IA0M\ri\' \ Luc\ .e.....r\ ow 0._61/1..ts PHONE # <br />020,,- ----4.5 - 7 o3 <br />Ext. <br />FirmAer t pREN, ,Ao.i.A. 1,,,,y je._ Fax # <br />( ) <br />CITY.k._10 0,...... tl:Nr) STATtA <br />ZIP 95-0206 <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: ittfa_ki by2 6 DATE: c7/ -20 ) 5" <br />PROPERTY / BUSINESS OWNE10- OPERATOR / MANAGER 0 OTHER XUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locate t the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses e4iwation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />my representative. <br />a TYPE OF SERVICE REQUESTED: F1-)(ttl vi,c- \i( , FE v . 4::,.0 <br />COMMENTS: <br />CP-- C rr-a_ t-n <br />miN do 08 ,OIL, AQej <br />ca r+. 1*447./.7?„,0490141,Coo, <br />ACCEPTED BY: Kt i ..2 EMPLOYEE #: DATE: / 7 /1 i.) <br />ASSIGNED TO: H,44 EMPLOYEE #: DATE: ' 7 1 / i <br />Date Service Completed (if already completed): SERVICE CODE: P/E: <br />Fee Amount: 4f$ •t _' - Amount Pai /5-01 c),D Payment Date <br />Payment Type (1 ' Invoice # Check # Received By: z , <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)