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S. '6 <br />SAN .IOAQUI LINTY ENVIRONMENTAL HEALTH OARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />JZ F-1- Ar I L C� S o 1-1 t -(E- <br />Cf <br />CITY S X-C, - O <br />y s-;3 <br />OWNER I OPERATOR '^^ A� <br />0 1 1` STC P y y\ �T'� t/ 5 r <br />Q V' <br />r <br />CHECK If BILLING ADDRESS <br />I Zr�l <br />FACILITY NAME <br />L) t l� S To t� <br />SITE <br />\A/ <br />L O V l S E AVE. <br />W A� �T t- C A <br />1193.1(0 <br />,ADDRESS <br />( 1 q (DStreet Number <br />Direction <br />Street Name <br />C ity <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />�wI'( E:R (� R 15 rz. S T- <br />'7 <br />7 S 6 +- <br />Street Number <br />Street Name <br />CITY F 2 (M n pl T <br />STATE C^ ZIP 9 S' <br />PHONE #1 E)cT• <br />APN # <br />LAND USE APPLICATION # <br />(sro) 6SFSSo© <br />41 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION DE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR I C bI 4F— L W A f-0 t-( <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME WALTO�( F�►t C,/tc�r�ztKc�, y� C . <br />PHONE # Ems' <br />916 3:�3- It sz- <br />HOME Or MAILING ADDRESSFAX <br />�o z s <br /># <br />(yr6)-3�3- <br />CITY S X-C, - O <br />STATE C Ar ZIP C/ <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 <br />or 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 anFPVM EDERAL laws. / <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT C O I t!C rL A,-. L <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. (,(S7- J Ya.1 "-J t <br />TYPE OF SERVICE REQUESTED: IPC k,[ 21-- t% 6 r -W d y* r S P M� <br />COMMENTS: <br />SPN EPJ�\�W�PE MOPT <br />TN EN� <br />ACCEPTED BY: O L t UL, <br />EMPLOYEE #: 0 2 Z� DATE: 1 C 07 <br />ASSIGNED TO: �I u EMPLOYEE #: 2 C,-? DATE: <br />Date Service Completed (if already Completed): SERVICE CODE: , P / E: Z 3 U <br />Fee Amount: �� `74 . Amount Paid t Do Payment Date -2-910 <br />Payment Type Invoice # Check # 3 5a q Received By: 14 g- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />