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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SCO 7 .62 eigC0 <br />OWNER PERATOR <br />.- e722:--/-7 CHECK if BILLING ADDRESS <br />FACILITY NAME i <br />0-yt_ey.4_ <br />-4 <br />/./g2d 2- <br />SITE ADDRiE.S. i <br />( 7 i 7treet Number Direction Street Name /J-2 <br />ip Code°6 Z <br />HOME HOME Or MAILING ADDRESS (If Different from Site Address) <br />5 (1/ <br />i <br />1 Street Number ,-5 /4a:-:"144 111///4 Y <br />Street Name <br />CITYS /C2C- * /C-2P' <br /> <br />STATE ZIP <br /> <br />6.:C.Z, ?--S -2--° 7 <br />PHONE #1 EXT. <br />(zas 9-22 -,?U9 <br />APN # <br />0 9°12- <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />0 0 I <br />LOCATION CODE <br />n ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ),V-2 7— ee- CHECK if BILLING ADDRESS Et) <br />BUSINESS NAME Zoii 6.17e-d4 eC" 19)/ '4a6.) 2_ PHONE # EXT. <br />'-,.i' , a <br />HOME or MAILING ADDRESS s• W _s-X6//..7)/4 ppyl y <br />FAx # <br />( ) <br />CITY _c" /c2 (/ 70,4/ .-6?,?-ATE ZIP is 77 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 Of <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 I BUSINESS OWNER 1 OPERATOR I MANAGER El <br /> DATE: 0 01/// <br />OTHER AUTHORIZED AGENT El <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: FOC) j.. Via VA' c C c ‘, In 5 . CY -1 Pilj i". <br />COMMENTS: IED <br />14C-k1 rh CY1CLA V C2-In i C_LJL> APR / r <br />sAtv , u 2018 t.....o,iQui <br />ileiivviRON Al COUN rii op..41EivrA, 71' ---AR ra.-- .7017 . <br />ACCEPTED BY: di nA-QA/1-(2-"6 EMPLOYEE #: DATE: q 1 (5 [d <br />ASSIGNED TO: L .) ,L6, , wicw\gc-, EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: CU) ( P / E: 1(9 03 <br />Fee Amount: 5 2 4-..-Q Amount Pai /5 Payment Payment Date <br />Payment Type Type Invoice # Check # Received By:/i110 <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)