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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />IZamailc A 14 tdrtono <br />CHECK if BILLING ADDRESS <br />FACILITY NAME l 4_ p <br />,N_CA ri I e_ A _ <br />°lig, 'toe-, <br />To . i irn <br />SITE ADDRESS t30 c-5 <br />',Street Number _ <br />e <br />Direction <br />,,,, 20 <br />Street Name <br />.-k--oc.kl-ovi <br />City <br />"15.20_5 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 5"1 CP '5 IC L Lo cAA-rzy too n__4 Street Number <br />u\)cAcz_v (3c, Kcl <br />Street Name <br />CITY <br /> <br />C q <br />ZIP <br />) <br />STATE <br />4C CA +73V \ q5 01 )5 <br />PHONE #1 Exr. <br />00 )1405 -5C kiC <br />APN # I LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />54 Ii4 .P <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHoNE# <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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,ST ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: I-La uvicy-)0, VA . <br />PROPERTY / BUSINESS OWNER0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 samsime it is <br />provided to me or my representative. <br />nrebi: /4 <br />TYPE OF SERVICE REQUESTED: r L il, ) 0 4-t E C <br />COMMENTS: 410 0 9 <br />84V110 ‘ 4 Afil'iQuik <br />"Eib,A104,,,, Cou <br />' rl DE.13%747.411! <br />ii4"4 Eiv) <br />ACCEPTED BY: C I c.1/4 , 01 ; 0„,, ,AA Lot. e} EMPLOYEE #: 96) 2 er DATE: •/.14_1?....,..3 <br />ASSIGNED TO: C... leku Ain._ .A/2 1.) f O EMPLOYEE #: (72 e,--,..s, DATE: ;,/Z, 1/Z......3 <br />Date Service Completed (if already completed): SERVICE CODE: ) L,._, 1 P / E: g 2, , 3 <br />Fee AmountAtiXig 0 6-' Amount Paid <br />LILO (?) 4 <br />...__ Payment Date 3/212 o <br />Payment Type iaA) Invoice # Check # Received By: etoin„ <br />DATE: 3 I (9' 073 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003