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SAN .TOAQUPCOUNTY ENVIRONMENTAL HEALTIREPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1 <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />1' <br />( of= <br />L -E (-E -(� <br />3"jr <br />DATE: c? 2.7 r U <br />-am 6l/�2q <br />OWNER/OPERATOR <br />eki, 9e`V`cut-A C^©t <br />CITY cS�'LC3 <br />If BILLING ADDRESSf�� <br />FACILIT AME <br />Q ` ( V <br />SERVICE CODE: <br />SITE ADDRESS <br />Fee Amount: 3��o <br />c,,Jtre <br />Amount Paid ik' (L c7� <br />Payment Date?/;v711 <br />�sc��c:.�J <br />�ts3do <br />Street Number <br />Direction <br />at Name <br />Ci <br />Zi <br />HOMEor MAILINGADDRESS(if Different from Site Address) <br />b O\ tAC Street Number <br />K C e <br />CITY KcrleJ \ V <br />STATE ZIP, <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(?01) 1938-3Fi-1 ti <br />; <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CO <br />T _5tca. <br />t_5 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />L C G` �- Z o um -e- � �� <br />J ,! <br />1A . % ie--vc f -12-4'F (-7— <br />CHECK if BILLING ADDRESS OL <br />BUSINESS NAME <br />C6-/-f-J 6 ' -) & Tike CKJIC r e?-* Veef)'--r a -o crc -1-SO Q et s k i._1 <br />Q e-,e� eccT vers <br />` V\P- TLS --35-G TA4jt-H-C4�=te - <br />PHONE #-7 <br />5S <br />L -E (-E -(� <br />HOME or MAILING ADDRESS <br />3620 M- <br />DATE: c? 2.7 r U <br />FAX # <br />(SSEt) <br />444 — c 7 3� <br />CITY cS�'LC3 <br />STATE (: <br />ZIP q3-1 1� <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 app 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S A E and RAL laws. <br />APPLICANT'S SIGNATURE: DATE:14 <br />a-3 cwt v <br />PROPERTY / BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 14 Cc"wwro CCTC.I.: OEM ._ ,yell, <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title \N so <br />G <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located ale ^ TO <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses L <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same timNfCIS nV VN 006 <br />til <br />)OP, EgTN- <br />provided to me or my representative. SOP- os*l" e <br />TYPE OF SERVICE REQUESTED: <br />1A . % ie--vc f -12-4'F (-7— <br />H <br />COMMENTS: \f{ P-- Cbl.5 M <br />C6-/-f-J 6 ' -) & Tike CKJIC r e?-* Veef)'--r a -o crc -1-SO Q et s k i._1 <br />Q e-,e� eccT vers <br />` V\P- TLS --35-G TA4jt-H-C4�=te - <br />ACCEPTED BY: i*1 f <br />EMPLOYEE #: ®3 x / <br />DATE: c? 2.7 r U <br />ASSIGNED TO:^/(/� u <br />EMPLOYEE #: C) <br />DATE: C ZZ l <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: 23ve <br />Fee Amount: 3��o <br />Amount Paid ik' (L c7� <br />Payment Date?/;v711 <br />Payment TypeInvoice <br /># <br />Check #S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />