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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />Typof Business or Property <br />6VC-OCI 716(1-/lab <br />FACILITY ID # SERVICE REQUEST # <br />Gc 0.0 0 1- <br />OWNER a ERAT9R_ tty _,. / 0 <br />II alt 6:- ilitt- N <br />CHECK if BILLING ADDRESS <br />FACILITY NAME !"--- eioth-o_ A -kiv^-, <br />SITE ADDRESS <br />umber Direction 1 1 CU 41.443eet ft -I dm'/ 4'1- Street Name <br />Si4-0/^-(4) <br />City <br />q5-01 <br />Zip Code <br />Ho712MstillitVirRESS (If Qifleeint frorp_ Site Address) <br />,(-2),, 1,6ifl I— (LI Street Number 516 rlQ 14, 14-t- (,),/-- s treet Na e <br />CITYk_ifiteg_ CA , <br /> <br />STATE <br />P(ME 41 Li -)„. A EXT.APN <br />r-- 3 ie <br /># <br />s" <br />LAND USE APPLICATION # <br />Z L 1Y c9_)c - <br />Err. 7-- 13), #2 <br />/) (C44,41 ) <br />,IM 376 <br />3q t <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />. <br />REQUESTOR <br />()104 & 63h I (e Picd(16 <br />4CHECK if BILLING ADDRESS <br />BUSINESS NAMEOzvidid A kik (4) Okintit4e---- ( <br />PM/46# q3q-f?z,L EXT. <br />HOME or MAiLING ADDRESS3 2s y _.1 LyDrik Lo MIL Ct-- <br />FAX # <br />( ) <br />CITY iev kie) ci li Pt <br />STATrA ZIP 475—Ls q? <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:(4-6- DATE: q5 <br />PROPERTY / BUSINESS OWNERI.:;1---.--- OPERATOR/MANAGER 0 OTHER AUTHORIZED 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 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 pro me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 0 \) e,\A'k du C mw viAyu /1-47, <br />COMMENTS: A uG 08 <br />JoAn 201,9 <br />ovv <br />N i-) <br />AfirmEN7. <br />DATE: ACCEPTED BY: \st . yVVOVe. vk5) EMPLOYEE #: <br />ASSIGNED TO: Nc14/1 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: flIt P/E: ‘G <br /> t <br />). <br />Fee Amount: <br />\ q i <br />Amount Paid Payment Date <br />Payment Type y / <, Invoice # Check # Received By: <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)