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2013-03-28 16:29 Visalia Sales 15597320817 >�- 20 6 433 P 1/1 <br />SAN JOAQk 2OUNTY ENVIRONMENTAL HEALTH L Ai2T. � % .7 . <br />�VIENT CE <br />r, <br />sERvrc,� REQUEST <br />Type of t3uslness or property FACIU Y ID # SERVICE REQUEST'110` 413— <br />ENVIRONMENTAL <br />OWNER/ OPERATOR r j [ MENT <br />Carex if Bre ur►a arRtL: <br />FAClurr NAME <br />r <br />SIreADDRESS ,/ n <br />` 5' 1 Stmt Number Dincflen / T �� <br />HOME or MAILING ADDRESS (N Difforent from Site Address) <br />CrTY <br />PHONE #1 FT' APN #I <br />L ) g Z <br />PHONE 02 CxT. <br />45,146'G74a --� I G �2 <br />rah `AI,1" 7e- (..1 ✓C�� <br />/' strw•t N..n. <br />— STATEE zip / ,r- <br />7 j <br />LAND USE APPLICATION 0 <br />BOS DISTRICT ---ui"—TIoN <br />CONTRACTOR / SERVICE REQUESTOR <br />Rt:auFEsTOR -� <br />LZG t�l Q ¢'+� CHECK If �t,��CADOIat;aa❑ <br />Busmaas NAME ' / // I+ I PHONE$ <br />V ey1( �ci 1-cY �E �rc)jYccu� �I L�� 2-0e Cr72 <br />HOME or MAIUNo AOORESS <br />Fax# <br />CRY G 1 Y) STATE "ZIP e7.5- o * <br />BYLLDirg ACKNOWLEDGEMENT: 1, the undersigned property or business Owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN7 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 l 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, STATG and FEDE.RALlaws. <br />APPLICANT'S SIGNATURE! DATE:._/�/� <br />PROPF;RTY I BUNINeSS OWNER© OPERATOR/ MANAGER ❑ Orf6kAUTHORI7.ED AGICNT E3 d JJlzc�- <br />IfAPPLIC4NT is not the &LL/NQ PARTY proof of authorisation W sign is required 7 Arte <br />AUTHOR17A3aON TO RELEASE i'NF : When applicable, 1, 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 COUNv"N ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representativc. <br />TYPE of SERVICE REQUESTED; <br />COMMENTS: G <br />lir' L�, —�3 a 9:ac� <br />► <br />1�1 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATv <br />AssiGNED To: <br />EMPLOYEE#: <br />DATe: <br />Date Service Completed (if already Completed): <br />8ERVICECODE! <br />P J!"; <br />Fee Amount: Amount Paid <br />Payment Date <br />Payment Type invoice # <br />Check # <br />Received By: <br />EHO 48-02-= SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />