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SAN JOAG COUNTY ENVIRONMENTAL HEALTI :PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 r'a'ed I l i z 9 `� E <br /> OWNER 10 P ERATO R <br /> E' <br /> CHECK if BILLING ADDRESS E] <br /> P*Jpt T-rct,►e.� CeAte K 1-c- <br /> FACILITY NAME C JJ <br /> C I f wI- Tl-1011vt1k ! Z 1 <br /> SITE9A{D�DrRESS hut <br /> Street Number Ci[ection <br /> 1d V -1 CK -r-pa. Name 1 i City <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 650e L011145 ON--f Street Number Street Name <br /> CITY STAT —zip � f~ <br /> PHONE#j EXT- APN# LAND USE APPLICATION# <br /> 4W Y7q�d� <br /> PHONE#2 EXT. BOS MSTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR r <br /> REQUESTOR CHECK if BILLING ADDRESS ' <br /> 3 I;f'rJ C r.,0 n �= <br /> BUSINESS NAMEII PHONE# EXT. <br /> Pilot T'rtvel tPJ LLC s 1/9y^a&F7 E <br /> HOME Or MAILING ADDRESS FAX# S O <br /> SSra rls ©r.0 <br /> / f� <br /> CITY {pxj; Ile STATE T'V 'LIP 37707 77 0 <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 /> also certify that i have prepared this application and that the work to he performed will be done in accordance with all SAN JOAQUIN �? <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE'—J1 - 71-3 <br /> c_. <br /> PROPERTY I BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L� �f'pf.- ►d f ely 7e� a <br /> —�" c: <br /> IfAPPLlCANT 1S 170t ff7e BILLING PARTY f)1-OOf Of authorization f0 SfgR 15 Ie[J!!!r@d Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above � <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It IS provided t0 me or <br /> my representative. <br /> TYRE OF SERVICE REQUESTED: <br /> t <br /> 64A &YMF—Nlr- <br /> COMMENTS: RECEIVE <br /> NOV4 0 8 2013 <br /> SAN JOAQUIN COUNT' <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: V{ - EMPLOYEE#: 1 DATE: <br /> if <br /> V [ <br /> ASSIGNED TO: � .. tl EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE SERVICE CODE: 3 PIE: 30 <br /> Fee Amount: �� 0 Amount Paid YJ —F t �� Payment Date f"( Cb1 <br /> Payment Type ,f Invoice# +Check# 1��' ceiv d By: k <br /> EHD 48-02-025 SR FORM(Golden Rod) E <br /> 07/17/08 <br /> ki <br /> hF <br /> I <br />