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Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />\12-ra \Gt. mr.,,ni <br />FACILITY ID 0 <br />0 00 0 77 c-7_ <br />SERVICE REQUEST 0 <br />S12(1)) 8 (06-1.--3 <br />OWNER / OPERATOR G4 CuEcn if BILLING ADORESZ <br />FACILITY N. 7 otiNo (f\\A4 <br />SrrE AoonEss A 1\ <br />Street Number <br />1 9,01,), \-61 vensc , <br />Direction Street N$ A (.61. <br />. <br />City <br />0 <br />2 <br />5-Li <br />Zip Code <br />ROM Of MAILING ADDRESS (if Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PtioNE #1 Ex-r. <br />( -1k) (.4t 4k ?3 \ <br />APN # LAND USE APPLICATION # <br />... <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT I LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADORES ) <br />BUSINESS NAME Te-- -,-kA Incic rc Cit i-n G (6441A6 <br />PHONE # <br />(tarl I 4,ctS orb) <br />Exr. <br />HOME or MAILING ADDRESS FAx # <br />( ) <br />CITY I. 08....bk STATE G4 ZIP <br />c51-0 <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, S - and FEDERAL laws. <br />DATE: <br />OPERATOR / MANAGER 0 <br />OMER 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaltite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th . • •t. is <br />RE.CEivE L <br />TYPE OF SERVICE REQUESTED: <br />Commons: Pvir 0/ 2023 <br />SANjoA , <br />HEeNviR64k-'1„N CouN1 <br />ALM DEp'v'ENTAL A IRN E.A.1 <br />ACC:EPTED BY: WkA_ CS ,-0 EMPLOYEE #: DATE: 4.... -Lcs...._ <br />ASSIGNED TO: &S CA. C.— EMPLOYEE #: DATE: 4 ,z-Lc.5.-- ....2.3 <br />Date Service Completed (if already completed): SERVICE CODE: DCp ( <br /> <br />PIE: /0 0 .2_ <br />Fee Amount: ISk, — Amount Paid 67, 00 Payment Date 5A 23 <br />Payment Type VX-- invoice # Check # iic )i ,i-E 1,52_ Received By: <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNeSI <br />provided to me or my representative. <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11117/2003