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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />/ 2-1'7 2— <br />SERVICE REQUEST # <br />So 5 7 co Li_ cc, <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS .-1---, , <br />Street Number <br />N <br />Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />, <br />PHONE #1 EXT. <br />( ) <br />APN # <br />24 2 — i 7 0 --z_q LAND USE APPLICATION # <br />PHONE #2 EXT. <br />I ) <br />BOS DISTRICT LOCATION .5- CODE <br />.3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Mr . \L-t:Nit ,A -etk <br />CHECK if BILLING ADDRESSP <br />BUSINESS NAME --- <br />e"\--\ '_5". ?CDC+ \, ''r-A..\-e,S' \ YNi..‘ <br />PHONE # <br />(loCt) <br />, <br />...)9 53 CT <br />EXT. <br />HOME or MAILING ADDRESS <br />N ilk 6 h \ - cks..\•e_.. ckCk <br />— Fax# <br />( CA ) SLI. 5 <br />CITY <br />P , <br />STATE co_ ZIP <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 0 <br /> <br />OTHER AUTHORIZED AGENT <br />r).-tlitcq_...NrS <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: /2 F c IL( -c_"7-74K C.....4_ ,C...).4-.A.) CP g... Ce__ ......1 ji--,E. ,A4 0 sti <br />COMMENTS: PAYMENT <br />RECEIVED <br />JUN 2 4 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL 1-IAI..T1-i <br />ACCEPTED BY: 0 4,.._ i VEr 41f EMPLOYEE # : <br />DrAA7 NT <br />DATE: <br />ASSIGNED TO: -;)_..-44- Z...1— EMPLOYEE #: 45, 2....._(_S DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c-' _.. -2_2_ PIE: we, 2-- <br />Fee Amount: g 2_4- 0 Amount Amount Paid \ (:) — Payment Date I 1 2_t / )G\ <br />Payment Type l/ Invoice # Check # 3 k Lk Received By: Vc-&- <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)