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c)(2.0Arb\flo <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />k--Y--cl \c r <br />FACILITY ID # SERVICE REQUEST # <br />0-6 ZtiC Lq --\--f- s --v e-- <br />OWNER / OPERATOR <br />---\' r\ C:iricr 16 <br />CHECK if <br />.jk <br />BILLING ADDRESS <br />FACILITY NAME <br />C'CA \ .k 'k--D:\--C-t r \ n S k--1---C 1 S <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />(-Ai V \ r i v,--( c_A-- Street Number Street Name <br />CITY STATE ZIP <br />Li- ri-V\ vr c IA ci 5 .V3 0 An <br />PHONE #1 EXT. <br />( SID ) CALX:i • 37 9 <br />APN # LAND USE APPLICATION # <br />PHONE #2 #2 Exr. <br />( 614D ) 25c-i - <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME (:_ PHONE # 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 sami, <br />acknowledge that all site and/or project specific ENVIRONNIENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified (myth& form. <br />I also certify that I have prepared this applica on and t tV work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT E' laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNERI OPERATOR / MANAGER El OTIIER 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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: C 0Y• s 0 I 4-A-1- lb h <br />COMMENTS: <br />ACCEPTED BY: C . 1U\ I.PC 0 EMPLOYEE #: 99 2 so DATE: n Zg„..... •10 . ..-- <br />4.--44 <br />ASSIGNED TO: C- • 6114 t.) i do EMPLOYEE #: 9ig 2 Es- DATE: // ;—•••:e' <br />Date Service Completed (if already completed): SERVICE CODE: 067 PIE: <br />Fee Amount: /cir Amount Paid <br /> <br />Payment Date <br />Payment Type 0 jv a Invoice # Ae,..-CrEcAiit., 7 5- 2.(....a 8i_kpo Received By: <br />DATE: /05/4 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003