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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITYADIt <br />0 0 eliCICT 5RON63)(80 <br />SERVICE REQUEST # <br />OWNER! OPERATOR <br />, Maur( C(0 CO rre et <br />CHECK if BILLING ADDRESS <br />FACILITY NAME,...\...ct <br /> CO CO V9 <br />SITE ADDRESS <br />/4 11- S Street Number Direction <br />)n ton 54* <br />Street Name <br />5 As i'l CIC4-011 City <br />.10 ca <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />€4-73 S. V nes4 90 Street Number Street Name <br />CITY, STATE ZIP <br />ri-enCh cqaii7 ot9, ?S'03 ) <br />PHONE #1 Exr. <br />dO, ) '03 <br />APN # LAND USE APPLICATION # <br />PHONE #2 #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME -1-cvos <br />Q3 rVeCt -14-rd• <br />PHONE # <br />a'? ) CO3 ( <br />EXT. <br />HOME or MAILING ADDRESS <br />-S '? S. Q kg eS -V Ycl rt-s•AL.4 \ at.-p-- <br />Fax # <br />( ) <br />CITY \ CAfl Ca r've SaTE <br />ZIP <br />SE <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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Mak:Pt/Q-6 CcsseViZcs— DATE: <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 />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. <br />TYPE OF SERVICE REQUESTED: 3 ($0( \r‘ C h-e_c_1( <br />.., ike;40#17., <br />COMMENTS: Dec , <br />84V Jell, I ? 2t)0 L., _,„eir„. <br />IletkinfiliigkiiN Co <br />rilttPAL,4147:4/449 .Trilf - EN?. <br />ACCEPTED BY: U(Avtio G ' EMPLOYEE #: q y30 DATE: 1)1 -7 1,, ..0,- <br />ASSIGNED TO: 4(ad14n1'l t L ' EMPLOYEE #: 45 jij DATE: !2-f ' <br />Date Service Corr'pleted (if already completed): SERVICE CODE: )...,_3 PIE: WO / <br />Fee Amount:4 L_6 (,. Od Amount Paid <br />bq bte.--- Payment Date --° <br />Payment Type aa,Ohz Invoice # Check # ..e.... Received B : ell_57--d <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)