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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IMPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />C . 0 I\) DO S <br />FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME cAc, p c--07‘F\ Cl -C-5 --0-)(L4-0.5 <br />SITE ADDRESS (31 <br />Street Number Direction <br />N\ 0 r-cfccn <br />JStreet Name C) _ Zip Code City <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Ci-n, STATE ZIP <br />PHONE #1 Exr. <br />( I . <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext <br />( I <br />BOS DISTRICT LOCATION CODE <br />NTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />05-10 C, ra krk- 9..R 9-A .- NI C-' <br />CHECK if BILLING ADDRESS CAN <br />BUSINESS NAME au,s.vorr\ li,061._ szEri\ 0 tz. 1_1 N c.7 PHONE # <br />(209) <br />Ext. <br />S3?-65o0 <br />HOME or MAILING ADDRESS <br />tirk UbmC_ PO <br />FAX # <br />( 201 ) 53-7 — QV 6S9 <br />CITY <br />g- s <br />STATE ok ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned propert) 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: DATE: 9 <br />PROPERTY / BUSINESS OWNER El 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 same time it is <br />rovided to me or my representative. , <br />TYPE OF SERVICE REQU <br />. <br />STED: J2.4) I az) k-c". / j Cr b P2100-,2>\, AgriviENT cP/vED <br />COMMENTS: sEp i $ - 1 23 1 <br />91.0.4t4 (WI <br />SAN JCAQLJIN r ,.,=_Nt/iRovi -OUNTy <br />' ''''L-T -1 DEpo'"ENTAL <br />' AR TMENT <br />EMPLOYEE #: Ft, y 9 DATE: ACCEPTED BY: ';::7° ,e_ <br />ASSIGNED TO: () ) & tad pa 4442 /iv_ EMPLOYEE #: Z, ( 3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 5 zez., P/E: <br />Fee Amount: )..... -5 b '`-t) Amount Paid 02-- — Payment Date <br />Payment Type <br />l, <br />Invoice # Check# /32.& 5 Received By: Li,3 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/200 <br />, , <br /> (11 Yrio, <br />- 2011