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SAN JOAQUIol COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I A (/ <br />.,:- _ <br />O 1 Nil', FACILITY ID # SERVICE REQUEST # <br />,5-pc.0-7(e)351 <br />0 NER / OPERATOR <br />/1/V le9 47194/1/ <br />CHECK if BILLING ADDRESS <br />/ FACILITY NAME <br /> -1, <br />SITE ADDRESS rt ,,A ,,0 <br />27 2? Street Number <br />, ii , , , <br />Direction Street Name <br />-.( o( <4 A)) City -.",,i 0-1 <br />la Code <br />HOME Or MAILING ADDR SS. Different from Site Address) <br />U1 Street Number ,i( Street Name <br />Crry STATE ZIP <br /> <br />PHONE..#1 • <br />(1 k).) <br />APN # LAND USE APPLICATION # <br />PHONE #2 ea. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU ESTOR 444/7/1/ ,e.-,-4 •again/341 CHECK if BILLING ADDRESS <br />BUSINEsS NAME (17(12-4 v.../.1_5- 6.----/... r 0/:/.../.." yr# Err. <br />HOME or MAILING ADDRESS _.... F.,074, <br /> <br />27 2 y PA <br />FAX # <br />( ) <br />CITY ID c eJ, DA/ C(4-- STATE (7V 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: DATE: 7 0 '2— ,7 <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 provideptii me or <br />my representative. 44Y <br />Title <br />TYPE OF SERVICE REQUESTED: f 2 VeAti Cje 41Tef-i)V) <br />,. rirtes,ii <br />COMMENTS: <br />- 1 OW nerr fZeGfc4-iva.fvtz - <br />c 0 2 2 <br />Sou/0 <br />ii ENV/1411N C - •Ek roi 044EA, 0 <br />OrP4/174 <br />ACCEPTED BY: EMPLOYEE #: DATE: 12/2/11,2 <br />ASSIGNED TO: LeArter Hillnk EMPLOYEE #: DATE: f2/9. p(„. <br />Date Service Completed (if already completed): SERVICE CODE: ,..c6,67 PIE:(u,c)3 <br />Fee Amount: 4 1-1-aP Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08