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_ 8188423716 p.2 <br />Oct 09 06 09:55a <br />P R Er�r:eering <br />SA1N <br />JOAQUIN COUNTY ENVIRONIIIENTAL HEALTH DEPARTMN <br />ET <br />Type of Business or Property <br />OWNER I OPERATOR <br />FACILITY NAME ` / ^ ^7 - L_ r�J q <br />SITE ADDRESS Yif.� IDL F��MG1'y'i <br />CE REQUEST <br />FACILITY fF <br />VFp � z <br />HOME or MAILING ADDRESS (It Different from Site Address) to <br />CITY <br />PHONE#1 <br />(599) C;� PSS — <br />PHONE #2 <br />(!.A <br />CHECK if BILLING <br />Exr. APN If ` O -I 1 O I <br />223 1 <br />En. <br />CONTRACTOR/ SERVICE <br />ZIP <br />LAND USE APPLICATION # <br />BOS DISTRICT <br />I, <br />Jr <br />BILLING ACKNOWLEDGEMR V r, me uuuc+�.ry�� r- r-1--- <br />aCknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN711om1y charges assocralcu W+�• ••••- <br />activity will be billed t0 me or my business as identified on this form. <br />I also certify that I ]lave prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinonce Codes, Standards, STATE and FEDERAL laws. � , i,'2 -90(o <br />2 -OO (_ <br />DATE: V1` 1 `fes <br />ppPLICANT'S SIGNATURE.t"� �t �e'ai <br />OPE R / MANAGER ❑ OTH R AUTHORIZED AGENT yM <br />PROPERTY/ BUSINESS OWNER❑ Til to <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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, geoteclnlical data and/or eble and <br />at <br />same <br />assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTALHEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. _ ^ <br />I .-,�rv-lttCrT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: C) rL.1 ---' ° plllu /AT/ifl <br />Date Service Completed (If already completed): <br />Fee Amount: S'�Q Amount Paid <br />Payment Type L--�' I Invoice# <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />EMPLOYEE#: �7�/���� �� <br />EMPLOYEE 1: Vim2 <br />�7 SERVICE CODE: <br />c Payment <br />Check # 42'7% <br />NOU 0 7 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />DATE: I// <br />DATE: <br />PIE: <br />Z 0( <br />Received By: <br />,SR FORM (Golden Rodi <br />