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SAN JOAQI COUNTY ENVIRONMENTAL HEALT /EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />ffVOO/hh 0fit..10 <br />SERVICE REQUEST # <br />b (tilii...i." <br />OWNER / OPERATOR <br />/ V ` '' C ..51.A I r 1 y CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />/ 6- 9 °Street Number Direction Street Name <br />7540( [ k ti <br />City <br />c/1,5- a_c7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm( STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTpq <br />( ( 17\ ir t-- til'ic-^ r dk CHECK if BILLING ADDRESSEF <br />BUSINESS NAME fi <br />(1'A) .547 `4"\ Pc t5eo-A-octe_( V\ i ( rk_o_..., <br />PHONE # <br />(9C1 ) 6 3-7 <br />Da <br />HOME or MAILING ADDRESS FAx # <br /> 3 !---±:5-- 5-9-00 <br />CITY , _ cA -c k e. --) ra, <br />STATE ZIP 9°453 ci <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: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER CI OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <br />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 />rovided to me or my representative. <br />e-LL <br />TYPE OF SERVICE REQUESTED: <br />4r COL Pre441,/igWi0,135 <br />COMMENTS: PAYMENT <br />RECEIVED <br />MAY 17 2012 <br />SAN JOAQUN GOUNTY <br />ENVIROMAENTAL J..- _ <br />ACCEPTED BY: EMPLOYEE #: DATE: 7 2, 11 <br />ASSIGNED TO: elote-14204 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: *-7/2...--- P / E: 1420 2„„ <br />Fee Amount: Amount Paid Payment Date \_4^,--i li 9 i <br />ved 7 <br />Payment Type / Invoice # Check # i ity,-, Rec y: <br />bJ DATE: <br /> <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003