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SAN J. , UN COUNTY ENVIRONMENTAL HEALTH DEP MENT <br />SERVICE REQUEST <br />Type of Business or Property <br />5u,) i (Inn') i Pco / <br />FACILITY ID # SERVICE REQUEST # <br />• OWNER! OPERATOR CHECK If m 1 (97(1E1 I err e(' 1 o . BILUNG ADORESSO <br />FACIUTY NAME ho me <br />SE ADDRESS I 5s j 0 <br />Number Direction TiciircAL.h pi- Street <br />svockriy) <br />City <br />ci 5c-.20q <br />Zip Code <br />HONE or MAILING ADDRESS (If Different from Site Address) I 2?75 <br />Street Number 1r i•I / id <br />1Y) <br />Street Name <br />STATEco ZIP <br />CITY .e) r-l- 6 rCiEa0 <br />PHONE M 11-1 1;-- c <br />T707) 9 toi4- 7 % V <br />APN # LAND USE APPLICATION # <br />1 r Jr) • <br />PHONE #2 <br />120.9 277-it 7(0),— Bob <br />BOS DISTRICT LOCATION CODE <br />ERVICE RE UESTOR _ <br />REQUESTOR i -no r Li H_ (1 1ki c CHECK if BILLING ADDRESS II <br />BUSINESS NAME Pa 1--c-iu- Poo(s ic -) s ,..33 (.4 .3 3cra PrA <br />,-bcii. i o C y .: 1 ,. NOME or hi/4JUN° ADDRESS 73-70 1y-se. 5 FAidal:c4 ( 53,4 <br />STATE C) CITY L.......e. ; ZIP ‘i 5g 4-/ 0 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent 01 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: 47)7 )ajt--1 7- -( Ale---C--4 DATE: (. ' 1 —7 4 (1 <br />PROPERTY / BUSINESS OWNER CI OPERATOR / MANA El OTHER AUTHORIZED AGENT P Cc)r)--/Y-Ci.0 f--r) r <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 />TYPE OF SERVICE REQUESTED: Pre, - p ick_5(e r--- -1_ rie_-_-,PecliZYA <br />COMMENTS: <br />ACCEPTED BY: lip EMPLOYEE ff: DATE: _CI —tet_ <br />ASSIGNED TO: POP di .... :arN,........ EMPLOYEE M: 50N DATE: <br />.1 <br />Date Service Completed (If already compIeted): SERVICE CODE: Sr- 22-2_, P / E: <br />Fee Amount: .--)_ 5-0 , ,... ‘2.... Amount Paid .2, 97) ___ Payment Date <br />/ 0 Ti 9 , <br />Payment Type ki I L., invoice ti Check It Received By: <br />El-ID 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />c)(1 c 0-1k - , <br />k\kic to -ici -