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I also certify that I have prepared this application <br />CouN -ry Ordinance Codes, flier. TE and <br />work to be performed will be done in accordance with all SAN JOAQUIN <br />DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />t\(V1‘( l_ —--- <br />FACILITY ID # <br />Noko <br />SERVICE REQUEST # <br />Qco 73-7,-.., omp,opubwoR <br />CHECK if U LisA D•-)1•30A4Q <br />BILLING ADDRESS <br />FACILITY NAME <br /> ( . <br />SITE Arinr4Cce <br />1117 . Street Number Direction <br />uxhor-S C'wt-e--e-4— <br />Street Name S?S-DUX--- City <br />Cl U-0 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />(Al Street Number 10,ff.r-,e_43 ,3 De__ <br />Street Name <br />Cm( STATE ZW <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />uu-i) SIC( - 1-00 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESSEL <br />BUSINESS NAME <br />V---00A \ C.& C)C- `--INiZA 0--1 <br />PHONE # EXT. <br />( 24) 4 sq--7, 37(oo <br />HOME or MAILING ADDRESS <br />ca ( ,S ,A <br />FAX # <br />Crry 1\i„Pd.-A-1 STATE ,— ,- k___.1 - \ ZIP q -5---7 -7 <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 />PROPERTY! BUSINESS OWNERJA OPERATOR / MANAGER 0 • THER AUTHOR ED 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 provid•Ato me Of <br />my representative. A Vi /4 <br />TYPE OF SERVICE REQUESTED: P00 -{. _17(-2k i ( 42 Yrt/Y( - CY—) IN <br /> <br />„ a , <br />COMMENTS: JOL <br />2 7 SolAi 2L <br />.‘ iv _ EIVfrfr ,QUOv .,., t-c.) <br />"°cP4/.1/rAi rkft <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: Mekic.,--f rl---cse-A--+,1 EMPLOYEE #: DATE: <br />Date Service Service Completed (if already completed): SERVICE CODE: ,..-C..)C I 1 P I E: <br />Fee Amount: 41 4, co Amount Paid Payment Date A <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)