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SAN JOAQUIN ‘;OUNTY ENVIRONMENTAL HEALTH DEHARTMENT <br />SERVICE REQUEST <br />i <br />Type of Business or Property <br />/ . <br />a 6//i-LE1--LS?Y'OCIO C_Y". <br />FACILITY ID # SERVICE REQUEST # <br />S ,e 6O1 Icite) <br />NER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME IN c <br />-1---IA 1 C-c he._11•E -0 e it 1.-6 --' -1-/T •iriS <br />SITE ADDRESS 3 laci <br />Street Number <br />L:-- <br />Direction <br />se c_ho rA A t' c <br />Street Name <br />Sts ct\- -1--d, X,) <br />City <br />q:SL 6 <br />Do Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry <br />-5k. <br />STATE ZIP cm 215 <br />PHONE #1 <br />eiPCf ) 1% l 7 - ?7- C / <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />(zey) I/ 00_ 116( S i <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br /> ) <br />.. <br />fte t /l-- CD --- E tik i S Oig ei E. <br />_ <br />CHECK if BILLING ADDRESS 11 <br />BUSINESS NAME ei ]eid(1.6.1,e_c:7 I s --1:) ro du c or PHONE # EXT. <br />HOME or MAILING ADDRESS <br />39Zq e CeC_firo 1/1(/'-e—. <br />FAX # <br />( ) <br />Crry ,•._:).4., STATE c...- ,p_ ZIP L7/7-7; - - <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 WS. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER "----"---o;ERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICAN iS Of 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 provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: -7 '--),----• <br />, <br />PAYmeCOMMENTS: <br />RECEivi <br />APR i 5 20 <br />SAN <br />ENVIR,074"v COI HEALD kNr44 , , ACCEPT BY: --• EMPLOYEE #: <br />i Dtp <br />ASSIGNED TO: ,/767,-2A/ EM PLOYEE #:OGy:...ejG:2 DATE: <br />Date Service Completed Kalready completed): SERVICE CODE: <br />Fee Amount: 730. (c-) Amount Paid 4,t30 • co Payment Date 4ks- I T <br />Payment Type 0A,4k, Invoice # Check # Received By: ")& <br />- DATE: <br /> <br />/5 <br />Title <br />EI-ID 48-02-025 <br />07/17/08 SR FORM (Golden Rod)