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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property. <br />Igo& le, -Gidb CetZi- <br />FACILITY <br />fii- civ <br />ID # , SERVICE REQUEST # <br />C---DlZji 7 <------)Cd--. <br />OWNER! OgEBATIOR <br />-Fred-410; 4-1'141e-Cr CHECK if BILLING ADDRESS EJ <br />FACILITY NAME le_f_A 1_10t; lit <br />SITE ADDRESS I 7, 3 <br />Street Number Direction <br />zTh.._, <br />r) .-/ (ii) / 0 5/ <br />Street Name -)(k \ Zip Code <br />HOME or MA(LING ADDREp Alf DifferentMite Address) <br />if I, VO I I Ct Street Number Vdip2/64, Street Name <br />Crry <br />NCO4eCek. <br />STATE CA_ ZIP 9,5357 <br />PHONE #1 / EXT. <br />1703 A94 — .79)K <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR Md. Attivsr CHECK if BILLING ADDRESS, <br />BUSINESS NAME <br />''ir-g /44- 6 . <br />Pordr62: 0-7— ,1 -7nd Exr. <br />HOME or MAILING ADDRESS AM i. i <br />V d i gee- FAX # <br />t ) <br />CITY Aik,i,geck STATE Zip ----37 <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 Or <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, ATE and FEDERAL laws. <br />APPLICANT'S SIGNATUR_f_E: DATE: <br />PROPERTY! BUSINESS OWNER T / 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 Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: 1-00d- Va),Izo 7-7oic), <br />COMMENTS: <br />ACCEPTED BY: (Cl <br />/V76/Vi EMPLOYEE #: DATE: 2 ./) .5 <br />ASSIGNED TO: in. V-5-, i ry-) EMPLOYEE #:, DATE: 7/ 1 <br />Date Service Completed (if already completed): SERVICE CODE: 06, / PIE: j :, 0 3 <br />Fee Amount: 4 /30 (3) Amount Paid ) /-?0,()/ ) Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)