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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />S <br />SERVICE REQUEST # <br />C °11711 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />r)-)0‘NYIQ 11\ 0, )1 4 <br />FACILITY NAME i/ % 9 4 oc1oqq-41 <br />SITE ADDRESS <br />I LI 3 <br />Street Number <br />ET <br />Direction <br />NrN) t \O CO- <br />Street Name <br />54 0 C.k_ hni <br />City <br />C15:)-6S <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />-7 3 '3 Street Number .7-c"'"IJ" Street eName <br />CITY ,, STATE ZIP <br />PHONE #1 EXT. <br />(769) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />--c.k-k4 ov \ <br />PHONE # , <br />-,),3`). ) lo -go uc'c-1 <br />EXT. <br />HOME or MAILING ADDRESS <br />;2-)-y- c,cky <br />FAX # <br />CITY STATE - 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 />PROPERTY / BUSINESS OWNER Eif OPERATOR / 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 i rmation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provid <br />my representative. IVW <br />TYPE OF SERVICE REQUESTED: kktAl l L i/j7S I 466104 <br />"wcitib <br />AUG COMMENTS: 0 2 <br /> <br />SAN 21 <br />Jai <br />L., Eisitip,b QUIN C <br /> <br />"Zill. oi, <br />NbePApp.6'Air4 <br />ACCEPTED BY: Laa Ot c , EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 6(e, / P / E: <br />Fee Amount* <br />'M <br />Amount Paid Payment Date <br />Payment Type 77f.„,_ Invoice # Check # Received By: 7 , <br /> <br />DATE: <br /> <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08