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SAN JOAQUMI COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> Type of Business orSERVICE REQUEST <br /> Property <br /> reeLFACILRYID# SERVICE REQUEST# <br /> ER/OPERA R`� <br /> FACILITY E // `L-Mu <br /> � / D CHECK IT BILLIN DRDR <br /> SITEADDRESS <br /> u� <br /> Str9 <br /> eet/miler Dbeceonlr�a 95376 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Street Name <br /> a coos <br /> CITY v./ S e Numher <br /> GQ LIL S�llt Nam STA J ZIP <br /> PHONE J(1 En / <br /> APN R -25 <br /> LAND USE APPLICATION If <br /> PHONE#2 6 � <br /> ( ) SOS DISTRICT LOCATION CODE <br /> REQUESTO <br /> CONTRACTOR/SERVICE REQUESTOR <br /> p <br /> BUSINESS NAME+ GY .�>�n CHEOCHBILLING ADDRESS <br /> /!i K' Ear. <br /> HO E Or N�gILING AD R PH <br /> CITY _/ ) <br /> i <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned roe STATE ZIP <br /> Property HE or bDSID053 DEPARTMENT <br /> operator a authorized agents same, <br /> B oING that all site and/or project specific ENVIRONMENTALrsignePropHEALTH <br /> or activity will be billed to me Or my business as identified on this form. <br /> hourly charges associated with this project <br /> I also certify that I have prepared this application and that the work to be perfo <br /> COUNTY Ordinance Codes,Standrmed will be done in accordance with all SAN JOAQUIN } <br /> Standards,STATE and FERE <br /> laws. <br /> APPLICANT'S SIGNATURE: r <br /> PROPERTY/BUSINESS OWNER DATE: <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BLLLINGPARTY proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of thepropertyTitle <br /> above site address, hd at the <br /> ereby authorize the release of an <br /> information to the SAN JOA UIN Y and all results, geotechnical data and/or environntentaVsiteo assessment <br /> information <br /> Q COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> provided tome or my representative. as soon as it is available and at the same time itis <br /> TYPE OF SERVICE REQUESTED: _- <br /> COMMENTS: Aft elMog �bt:�-7� <br /> y F2 <br /> `hut, 3 005 <br /> SAN JDAQQYN UNTM <br /> ACCEPTED BY; <br /> j ENTH DEP p�fMFNT <br /> ASSIGNED TO: _ EMPLOYEE#; <br /> DATE: <br /> Date Service Completed (If aim ady corn fated): EMPLOYEE#: <br /> DATE; <br /> Fee Amount: SERVICE CODE: O <br /> Amount Paid � c--n P/E: <br /> Payment Type Y�g•�' v Payment Date 6 3 D.� <br /> Invoice# Check# <br /> 5 / Received By; � <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br /> SR FORM(Golden Rod) <br />