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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> %J&— V ECE P.E vEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S' . ;v 0 Sl�zC6 7� � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME (�( <br /> SITE AD RESs4 CL <br /> b Street Number Direction Street Name Ci C'l�rC► Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> L'�/� U O. Street Number Street Name <br /> CITY/�a STATE ZIP <br /> CA 9 <br /> PHONE#1 IFEXT. APN# LAND USE APPLICATION# <br /> (9jSPHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 00 <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR MISMA <br /> ` le 't(� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> s` -0 7 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY e 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 /> 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 FEDERAL laws. ^ / <br /> APPLICANT'S SIGNATURE: _ -- = DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT Is not the BILLING 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 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 /> TYPE OF SERVICE REQUESTED: u�� �1� PAS <br /> COMMENTS: �1 ° <br /> 1N1 m `L 6 2015 <br /> N JOApVIN COt3NTY <br /> SA ENVIROM t4l, Y <br /> HEA�jN OE <br /> ACCEPTED BY: '-�C EMPLOYEE#: DATE: `] <br /> ASSIGNED TO: V(c) EMPLOYEE#: DATE: -2—jp <br /> Date Service Completed (if already completed): SERVICE CODE: c�,L, P/E: `3 j <br /> Fee Amount: �� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> . IL0�} S <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />