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SAN JOAQU11'.i COUNTY ENVIRONMENTAL HEALT L. )EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />P 0141;0 U Pa 1;1- ti) e V IA 0419/A OM t <br />FACILITY ID # <br />r-- il 0 0 O a (1 1 , <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />E (v1 6 ARC A o tmo Co o e i4 0 Akc..-s A sc oc. <br />CHECK if BILLING ADDRESS gl <br />FArtityz 4 az4.6 Eve:0 co \ je, co i4 <br />SITE ADDVZS 649w m <br />Street Number Direction <br />FSARCADERo '-i_ <br />Street Name <br />S TO cert.)NJ <br />City <br />qs115 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />IS 1 \ Street Number <br />A ) A $41. U0 &"x, NA Cti61- <br />Street Name <br />4r5" <br />CITY yrucKTOQ ()SATE ZIP cl (1520 i <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) II <br />BOS DISTRICT ........_ LOCAlION CODE <br />R / SERVICE RE UESTOR <br />REQUESTOrt\ <br />IC6€01:r (?) FAA, &-7-7" Cji ZY1 _ 6 "I g25--‘ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMEr <br />P 1412K-Lim` c Pao (... i e-Rtfi cr PHONE # <br />A pli ) co e- os9 EXT. <br />HOME or MAILING ADDRESS.FAX <br />p. b . 6 ox (z.1 1 3-: # <br />CITY c.r.0 ed<ro) 04 STATE ZIPq 5 <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: A KA-77A fe" / 4A... DATE: El / q7° 7 <br />PROPERTY/BUSINESS OWNER!: OPE OR/MANAGER 0 OTHER AUTHORIZED AGENTA a)"- <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />TYPE OF SERVICE REQUESTED: Po 0 I---- (c pi c, t o <br />COMMENTS: V 4 s 1 <br />OC.1 W NCO GON3`- <br />‘,4 0 P`Ckci?\1*10,14q14C <br />ACCEPTED BY: BY: OL-i. kJE-c e-A- EMPLOYEE #: D 24- DATE: 812...c (0 <br />ASSIGNED TO: 19.L.04,,,4 2.44_ EMPLOYEE #: 6, 243 DATE: c-1-/1s (0c, <br />Date Service Completed (if already completed): SERVICE CODE: 1---- .. 2-2— NE: 3(0 62_ <br />_ <br />Fee Amount: all ,1)-1) ,;.....gco Amount Paid a 3 o - I Payment Date cel 2_,s,1 6 1 <br />- Payment Type - Invoice # Check # \ \ 1 S Received By: (---c.,__ <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003