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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH "ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />f)-- 66 1 <br />SERVICE REQUEST # <br />3t7S L17 Lo <br />OWNER! OPERATOR I <br />AY)a 7u ,,-, 1 rA el_ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />A <br />1., _ <br />O. 03 t-- 0 •C ti . CA.- i --. <br />SITE ADDRESS ADDRESS <br />1.1 1,1 3 0 94elanYar I Direction In t 1 (..) °SK1t WeV1 S A-- S (_. Kt ( (194.0 b Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Li LO C ) CI- V- 1/4 - b r Street Number , (.. < I opt Street Name <br />CITY, ,f C_ STATE ZIP <br />PHONE #1 ExT. <br />(71q 77 '2. 3_ -a 6 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />I ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR L.. . IlvIck:G 7u,n1c1-,.. <br />PHONE # <br />(77) <br />CHECK if BILLING ADDRESS i <br />EXT. <br />7--7- S <br />BUSINESS NAME_ <br />---.. C A. li<AD'Vt .1.-- V\c -4:4- q PE (iu."---) <br />HOME or MAILING ADDRESS <br />ti 11,4•51 C—(CV r l'c SI ‘c <br />FAX # <br />( ) <br />CITY C...::).1 I .." STATE C tN ZIP VS g i S <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 />' <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / M WAGER 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 pribAlled to me or <br />my representative. 4 )0. <br />TYPE OF SERVICE REQUESTED: F 1.-)c, A ve I, )1c1-6 iPispec 4100 <br />. Arirk.64.7,1,14,1 <br />Ato <br />COMMENTS: C t, 10ii lq ''e 0 <br />Nie,,,.:, LAccosc pl,k, i)(.4//')ber 1--)PF <br />Mc th.,4044.11' cold 7 44/02.4.04440t, <br />- ri F74/410, <br />ACCEPTED BY: sC-3...Q6 (---c4 EMPLOYEE #: DATE: ) 2_, 7,25-- i -7 <br />ASSIGNED TO: L ) k ) i-ft/til) <br />EMPLOYEE #: DATE: I 2- - - i ---) <br />Date Service Completed (if already completed): SERVICE CODE: P/E: I (p3) <br />FeeAmount: ...-.. ct) Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: / <br />Title <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)