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I�CI�CIV CLz <br /> SAN JOAQU*OuNTY ENvmoNmxNTA1L HEALTH 0ARTMENT <br /> MAR�WE,REQUEST <br /> Type of Business or Property CNVIRON1 TNTAL_/�FACILITY 1D# SERVICE REQUEST# <br /> 1r�-l <br /> _/� <br /> OWN R/OPERA oA k <br /> 5 t CHECK If Q!-LING ADDRESS IJ <br /> FA NAME 1 <br /> c ' <br /> SIrE DRESS <br /> 'Z-4h QCT. f eff.h�op, <br /> Street Number on Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> Curr STATE zip <br /> PHONE#1 APN# ^ LAND USE APPLICATION# <br /> O ( q <br /> 3 <br /> PHONE#2 BOS DISTRICT LOCATI Coup <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ' \ CfiECK if BILLING ADOREsslid '•' <br /> BUswESs NAME EL\'lE '-C�1NT'P�F}CT�S P NE# 1 <br /> HOME Cr MAILING ADDRESS 15CKI u.i 'I.�IAM �� FAX# <br /> L.JJ 'F YAM ( ')fv ) ,l <br /> CITY I el; ' g52L5 STATE zip <br /> RMLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> ackuqwledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or act.vity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicationand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standmds,STATE and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: l!n 1kmac DATE: I.j1L� <br /> r <br /> PROPERTY/BUSINESS OWNER OPERATOR/INANAGER ❑ OTHER AUTHORIZED AGENT pf21 `t-,NTAZI�i <br /> If APPLICANTisnotthe BILLINGPARTY proof of authoriAdon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: when applicable,1,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 envitoamentallsite assessment <br /> information to the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 1� y + f 4? <br /> RYI <br /> TIDE OF SECEREQDEsTm: CJT� I�E'1Q1Y,- l �� Y. `•�C�IVIli�S a CF NT <br /> t <br /> COMMENTS: <br /> N[IS��p AV <br /> �Nq Aly <br /> ACCEPTED BY: �... EMPLOYEE DATE: Int t <br /> ASSIGNED TO: ��\�A, EMp1AYEE M DATE: -+r <br /> Date Service Completed ('rfalreadycompteted): SBWECODe ` Gi PIE. <br /> Fee Amount: '7710 Amount Paid 3 70,49D Payment Date // �S- <br /> Payment Type I t, Invoice# Ch # 7�G�SS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />