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SAN JOAQ COUNTY ENVIRONMENTAL REAL APARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FOOCk' k f CA % 1 .e (- <br />FACILITY ID # <br />._ <br />SERVICE REQUEST # <br />6i2 tjD /0 - 2 -3 <br />OWNER! OPERATOR <br />`1e.5i(t1 N. alit( re % Am rim e- Co zdi r E"'"" A's°. <br />FACIUTY NAME 1....\.0.. Doti ,•• \....\....A wi viAvir6,2 Ei,i <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME Or MAIUNG ADDRESS (If Different from Site Address) <br />20 5 0 sfreetNumber VAcka y ici Street Name eiTy _k1c7(_ STATE cc_ ZIP <br />PRONE #1 EXT. <br />(2(e) 62 S to 35 1 1 <br />APN V LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR 1 <br />_ <br />es"c ri NJ. cci lit evc <br />CHECK if BILLING ADDRESS <br />BusiNEss NAME 1-64 Doak s k•inol Oa (tin/ ce/I 6D t o P" i23 0 — <br />HOME or MAIUNG ADDRESS 2 )G0 mack eici pi . FAX # <br />( ) <br />CITY '3-b1kirUen STATE 04. ZIP al SZLic--, <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 ENVIRONMENIAL 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 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 />6C 1(0 \\ • C0,61YeC <br />PROPERTY / BUSINESS OWNEJter OP TOR / 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 <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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Nan VI euu -Vby T--ati frn 11-P <br />Cameros: A YME.NT <br />ifi CEVE,0 <br />FE8 2 , 1 2019 SAN jr, , <br />A- AlCi'tf/A1 r' '-NVit? <br />ACCEPTED BY: \,I , Aikaitk (c) . EMPLOYEE #: t f 6,,mtH 0 1 Aii-y <br />ASSIGNF_D TO: <br />' Peank (V, \- <br />EMPLOYEE #: DATE: ' <br />Date Service Completed (if already completed): SERVICE CODE: -z 3 P 1 E: 1 LO 0 1 <br />Fee Amount et Li /-e , Amount Paid p z./5-(p , _ Payment Date 2 / 2 I 0 <br />Payment Type --p, .e.,6 1 -f Invoice # Check # Received By: t 6 <br />APPLICANT'S SIGNATURE: DATE: DQ--\ \n <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />f g SR FORM (Golden Rod)