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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />L_ <br />SERVICE REQUEST # <br />O 0 Mt <br />OWNER / OPERATOR <br />,,..--'-- (50 tki - a ts CHECK if BILLING ADDRESS c-Pz <br />FACILITY NAME <br />.. , <br />-K N(L-LitS otp( 7) u p u 5 (bi-( ci j T-09 a <br />SITE ADDRESS I S 0 i Street Number Dion <br />a 11 ---1-0 <br />Street Name <br />tt ci i• <br />City <br />(35 zelo <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />401 0 0 ('J . 4 IU0 (1 QM /Li I Street Number C /A Street Name CI 5 2 /2 <br />Crry I <br />1-0 C 1-4 4-0 0 <br />STATE c 14 ZIP e? 5 zi 2 <br />PHONE #1 EXT. <br />(20 9 32 - 0 c--/i9 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ..- i 5a <br />V 2.. <br />cz..... v e., s CHECK if BILLING ADDRESSP <br />BUSINESS NAME 2 ilci (t. s p opes triCk --r-ci 9 ut rfc4 <br />EXT. <br />P( H)ON E(;) 32.-----i-0 4-/1:2 <br />HOME or MAILING gr OREIIS , <br />Li q o 0 Q 9 -44- NI CA <br />Fax # <br />( ) <br />CITY 5 4_0 04,4 n STATE ( ii ZIP <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: <br /> -&J(A N <br />PROPERTY / BUSINESS OWNER I:St 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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: C-0(15 LA I 1-0-1/-011 A <br />Afr <br />COMMENTS: 6 ifitzo <br />NOV 2 8 <br />C 20/8 lianqt oc owAeArs-hip sAA,J0 <br />HEAL 7.,,, , 0AiwA/OU/Vry <br />r7 OFp/vs, rAi <br />ACCEPTED BY: E-st\itr .1-,rntot Z..../ EMPLOYEE #: 001710 DATE: <br />, <br />ASSIGNED TO: 1111,Actile, _F-avNry,,,,, EMPLOYEE #: ?t--i?tq DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 01.9 I PIE: <br />Fee Amount4 15 g_ • 00 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br /> <br />DATE: <br /> <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />07/17/08