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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Li/MIN/A& °Cr- — , <br />FACILITY ID # <br />I L., k-- 2.- <br />SERVICE REQUEST # <br />(_C) 0 & .. 3 f,c,2 7 <br />OWNER / OPERATOR e4r rV C, 2,hg3''‘/ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />1//C/ /4/5-1/ teW /4:3CL" <br />SITE ADDRESS <br />23 32 Street Number <br />_ <br />Direction <br />fl tio,61-,eso 5-4 <br />Street Name <br />57-erv7-4--/J <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) / AY, <br />Street Number <br />5triae-$4"- '7, r <br />Street Name <br />Cm -''_...,.., , _... , <br /> <br />,l-lerk< 7CA' ' <br />STATE cAet ZIP <br />eios <br />PHONE #1 EXT. <br />(A-41) q _ 55,/ 2 --- <br />AP N # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2-9t) ti '31 - 7 3r/ ( BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR A , <br />c--17 Y' g,k iZ-iciV -77-e-litir,7- <br />_ <br />-e4tis CHECK if BILLING ADDRESS <br />BUSINESS NAME M''. 1404 /4 ( er v ( g37---%qz— <br /> EX I <br />) <br />1 <br />) <br />Han or MAILING ADDRESS <br />" 6*C/1)04 6.7.' <br />FAX # <br />( / 7 &17 6 <br />C try 7,---cele.rbA) STATECAt ZIP 15,7 0 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 , . lineation ..al. • ... the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar AT'Ate i‘ KV laws. <br />. ly, „),---- DATE: 71/ 4 <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT% //eedoke-41,4,/ 6,4401~ <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: PóO t- i-C "r9- ,4E/4-1. P.-14..QA-(006.e..- /)1.--4(`-/ <br />COMMENTS: PAYMENT <br />RECEIVED <br />JUL 21 2011 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DFRAIIIMENT ACCEPTED BY: c9 C...4 vg4 e..04 EMPLOYEE #• o & DATE: DATE: <br />ASSIGNED <br /> ASSIGNED TO: EMPLOYEE #: to 243 <br />Date Service Completed (if already completed): SERVICE CODE: a i--- 2-2- PIE: <br />Fee Amount: -itt )._,...ft.f try Amount Paid -6 _,..IL7t . b --L) Payment Date 71-d.71 ( f <br />Payment Type (1,x L- Invoice # it t);.:1 71 5 Received By: _.,( <br />.._ •••• <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br />REVISED 11/17/200:a SR FORM (Golden Rod)