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SAN JOAQUIN ( INTY ENVIRONMENTAL HEALTH DF 1TMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />C ("1_ i k r, i /1/ y (,- )1 <br />OWNER! OPERATOR <br />7 <br />FACILITY ID # <br />( '?1 <br />SERVICE REQUEST # <br />6.1/e,00 &'103Pi <br />1 <br />d C i ?_- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME C,1- <br />SITE A)17,ESS <br />/ Street Number 2 HOME Or MAI NG ADDRESS (If Different from SiteIL <br />Direction <br />P ' <br />j ' StrIeNam (>1 Vt; 7•1-‘ • Zio Code ‘? <br />Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. _3 i 7 ), Ci Ori 7 J 6 <br />APN # <br />017 - 290-2-9 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />° osao no. ...se. DISTRICT 2_ . LOCATION CODE <br />/ <br />CONTRACTOR / SERVICE REQUESTOR <br /> <br />REQUESTOR \ <br /> <br />.7- <br />ff <br />t- c?)1(/(-) CHECK if BILuNG ADDREss <br />BUSINESS NAM , / / <br />'i /1 r vi /26 e 1 kfe : ' l.' . kCC-- <br />PoN6E1 ) 7 I 1 j...._.??ExT. <br />HOME or MAP trRESS i c -, ) <br />-7 , -3 r'''--7-1 C -/ L i y <br />FAX # <br />( ) <br />Crri, <br />' ci /1 CA STATE 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 • • laws. <br />APPLICANT'S SIGNATURE: DATE: — F 1 0 <br />PROPERTY / BUSINESS OWNERCI OP 1TOR IANAGER 0 OTHER AUTHORIZED AGENTR Co .,, 7 cjo-c^ <br />1.114.PPLW4AT is not the BILLI.VG 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. herein authorize the release of any and all results. geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRO IENTAL HEALTH DEPARTMENT as soon as it is available z nd at the same time it is <br />provided to me or my representative. 0L [S v'4 ,P74,4t - _ r <br />TYPE OF SERVICE REQUESTED: V , <br />commENTs: j i c m. • I 1 < le- 4-4-1)-/ _1,17c A A J (--. Jr „...) <br /> <br />.4c-- "-c .4-1 a v.i)-- .. r <br />0 )1 0 Iv 61 1 ic 4, -1c,../ 5 <br />771 q, 1 c4 r cii , <br />ACCEPTED BY: 0 c_ 1 ki,E i 41,4 EMPLOYEE #: 0 324 DATE: <br />DATE: <br />7/ / <br />--7(1 /(D <br />P i : 3(,02- <br />ASSIGNED TO: <br />tag640.14.2-* <br />EMPLOYEE #: 6 z.„„Ls <br />Date Service Completed (if already completed): SERVICE CODE: 5-2.2— <br />Fee Amount: IL 2_73 . tip Amount Paid /3 .2_,3 o. 6 D 0 Payment Date —71 ( i f <br />Payment Type Invoice # Check # 1„).....(4,..3 Received By: <br />EH D 48-02-025 <br />REVISED 11/17/2003 <br />PAYMENT <br />RECEIVED <br />JUL - 1 2010 <br />SR FORM (Golden Rod) <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT