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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />Facury NAME nX m ,i... e6i 4 <br /> 4, <br />a ,.._.i.,,t ___, ...fa___,, <br />SITE ADDRESS <br />C:20Z7 Street Number eV irection _ 171er Ad <br />Street Name ' t <br />City 75Zit?Ct?) <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />Street Number -- Street Name <br />CITY STATE ZIP . <br />.. , <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # e <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR , <br />‘-s-virVC4 4,i ... <br />_ <br />CHECK if BILLING ADDRESS a <br />BUSINESS NAME <br />44,7 - e_ A, PHONE # Ear. <br />HOME OrtilyAILINODDRES <br />e2 •-I ,F.4 <br />24:2? FAX # <br />( ) 327 - /...?o? ? <br />CITY /0 ee144r,,dq e STATE Z I P C15: :35 -,,g <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 or <br />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, ST • a El RAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 s'te address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />info. i to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />e or my representative. s.P -e_ cet,v . so- <br />TYPE ^ - ' EQUESTED: 143(022 ) /47C-A-01(:-t- <br />- - <br />COMMENT : 1,,./ <br />/4 <br />r''ZI <br />. s . t, i ENT <br />RECEIVED <br />MAR - 4 2011 <br />&,.,1',I JOAQUIN COUNTY <br />E K, %, IRON hi F KTAL <br />ACCEPTED BY: / <br />I <br />P e ,o, • <br />/ <br />EMPLOYEE #: 2,.../....? DATE: ell/ J./ <br />ASSIGNED TO: / <br />I <br />P , • i EMPLOYEE #: 62 Z1 3 DATE: S Li. i f <br />Date Service Completed (if already completed): <br />, <br />SERVICE CODE: OD- g PIE: <br />Fee Amount: <br />Invoice# <br />r <br />Oa <br />Amount Paid <br />t-t Lk — <br />Payment Date 3/ uy L k <br />Payment Type Check # S ri 0 b Received By: \(-j_,.- <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)