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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MA GER 0 OTHER AUTHORIZED AGENT VI C opt,fr-0-4,0 r- <br />DATE: <br /> 7- 9-bia <br />SAN JOAQU1 COUNTY ENVIRONMENTAL HEALTL EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1170-/-e i <br /> FACILITY ID # <br />3°C'/ <br />SERVICE REQUEST # <br />OWNER! OPERATOR <br />‘ 6 6 r 1/0 /6/ 5 CHECK if BILLING ADDRESS <br />FACILITY NAME In b/t, 1 6 *' C?"78 <br />SITE ADDRESS <br />_.3i./0 Street Number <br />A/ <br />Direction <br />---- 8 Aid. /ra 61 Street Name <br />7 f a c_v <br />City I <br />953 7( <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 Err. <br />0 O) 036 - z-19•06 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / <br />"13 itheite J Z <br />CHECK if BILLING ADDRESSES! <br />BUSINESS NAME A 1 , Pro ble07 "soc) / 5 <br />PHONE # <br />( VOS) 04)9- - /37 <br />D-Exr. <br />HOME Or MAILING ADDRE)S , , <br />5-40 (iPq 5 /leg (9t1t- <br />Fle <br />(/t) 4/9 <br />Cm ,..54,," ,7 -.4) 56 STATE (J ZIP 9. 57 a- 3 <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 d FEDERAL ws. <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 EkIVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />rovided to me or m representative. -P00 -FA4 /4-4^) <br />P AY MEN, ,-,' <br />TYPE 0 ERVICE REQUESTED: 4 8 / oat) V 6 B Com p bet A e.- nE covt-L, <br />com 1 <br />SEP 0 9 2°1113 </747,4,0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: co C. c EMPLOYEE #: dr.:23 21 DATE: q 1 q i ( 0 <br />ASSIGNED To: /Pee..4 .....„4. 7,k EMPLOYEE #: (0 2....4,..& DATE: 9/4?/( 0 <br />PIE: 3626 2._ Date Service Completed (if already completed): SERVICE CODE: _5-2_2_ <br />Fee Amount: 7/ 2.,c14.f, 6---i) Amount Paid 0,4 Lk , Payment Date <br />Payment Type Invoice # Check # IA 1-6 S <br />Received By: cyz„..--- <br />SR FORM (Golden Rod) END 48-02-025 <br />REVISED 11/17/2003