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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />,fITTEQT <br />Type of Business or Property <br />FACILITY ID # <br />SERVIC EQUEST # <br />OWNER I OPERATOR ` <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />Street Number Directian <br />�G—n � y - <br />Street Name Ci i ` ZiD Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />PHONE#1 ExT• <br />N # <br />EEMPLOYEE M Y b <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />{ <br />EIOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REQUEST ^ <br />� <br />CHECK if BILLING AD6RfSS <br />�r v lam\ <br />BUSINESS NAME � <br />� T{ � �, h� <br />� � � �C�'~ <br />(TLilly �OLISyN <br />SA NJ�IRON gp-kWE�t'�'T <br />HOME or MAILING ADDRESS <br />ACCEPTED BY: r� t v �C r <br />L1 <br />CITY ��j <br />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 or <br />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 o he performed will be done in accordance with all SAN JOAQurN <br />COUNTY Ordinance Codes, Stan ar ,TATE laws. <br />APPLICANT'S SIGNATURE: `'�`"`_� Q <br />DATE: 7 <br />p+ <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHE I]TuORIZED AGENT 11,[ <br />IfAPPL7CAmT is not theBaLINGPARTY, 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 />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: IJ <br />y <br />COMMENTS: <br />REG�IV �D <br />(TLilly �OLISyN <br />SA NJ�IRON gp-kWE�t'�'T <br />ACCEPTED BY: r� t v �C r <br />L1 <br />EMPLOYEE #: r} 3 2- <br />c�s& <br />DATE: fj Zq l 0 <br />[C <br />ASSIGNED TO: �P ,f <br />EEMPLOYEE M Y b <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: � � PIE- 2308 <br />Fee Amount: r©L) Amount Paid <br />Payment Date C1 I LI/t 0 <br />1312 <br />Payment Type <br />Invoice # <br />Check # U Received By: <br />EHD 48-02-025 .SR'FORIVI "(_old Rod) <br />REVISED 11117/2003 <br />