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Title <br />SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # __11 0 0 UO2-7 <br />SERVICE REQUEST # <br />OD 03°1,0 <br />OWNER! OPERATOR <br />Vi C, 11)‘r NthyttAti Sruforz-oti -121--avO CHECK if BILLING ADDRESS <br />FACILITY NAME 4'att) <br />(cc 0 <br />SITE ADDRESS "--/ 30 <br />Street Number <br />S <br />Dire ction C-0 0(S-tieletiN' 'a Sl- <br />C-ft)(10Vrt <br />City <br />q9:26 3 Zip Code <br />HOME OF MAILING ADDRESS (If Different from Site Address) (41.) <br />Street Number S o ec ilv ( Street Name <br />CITY <br />SW/ qb n <br />tir ZIP q574 6- <br />PHONE #1 EXT. <br />CM) rl 1 — 1 7 ILI <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR . , <br />V c.kbr maniA.6 Salazar -Bray° CHECK if BILLING ADDRESS <br />BUSINESS NAME -flOt t 0 L 00) <br />PHONE # <br />(zgh 27 1-17 /1/ <br />EXT. <br />HOME or MAILING ADDRESS LI Lil <br />S auJi S 4\ie <br />FAX # <br />( ) <br />CITY smoziy7 STATE <br />FA <br />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 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: U ,-C-t Jr S-10\ 10, ZA, <br />PROPERTY! BUSINESS OWNER 0 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 or <br />iv? my representative. <br />et) <br />/9 <br />DATE: <br />TYPE OF SERVICE REQUESTED: AO Etpers---1,444441 littte . 1Cio 1(1s-10,cl-fob, s„ <br />COMMENTS: <br />elK atI\ 91 <br />0 v 0(1 etfl li <br /> <br />6r <br />4A/ 7 1 6 <br />PA, u/ick j 2 <br />fidii)-1/17?04/4,c/Vz.006 <br />'Ili' 7-4,1-Z <br />ACCEPTED BY: La vtrn S • EMPLOYEE #: DATE: i 11(4;1/C1 <br />ASSIGNED TO: <br />VAa‘n b e i <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0(i) 1 PIE: )(s 03 <br />Fee Amount: 1 • 00 .2_ Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)