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29 14 09: 0?a Elit6V Contactors 120946342 P, 2 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTJII )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESSO <br /> FAcam'NAME mv <br /> $REAOORESS 1-1561, <br /> Str.tN.mbff Na.2 _ C <br /> Z1,Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number _ Street Name <br /> C'm STAT" ZIP <br /> PHONE41 <br /> Ezi. APN# �. LANA U i APPLICATION# <br /> (RA ) 941 - 226 . <br /> ll" Zl v�5 <br /> PHONE#2 EXr. BOSIDI rRICT LOCATION CODE <br /> ( ) C>iL C <br /> CONTRACTOR / SERVICE REQUEE TOR <br /> REOUESTOR ' <br /> CHECK If RUNG ADDRESS <br /> BUSINESS NAME P Ezr. <br /> HOME Or MAILING ADDRESS \ FAX <br /> ( <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: T, the undersigned property or business owner, Iperator or autborized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN[ 1 cH1y charges associated with this project <br /> or 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 to be performed will he Ione in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: fm � IAT�E,y: �CJZZ 1. f <br /> PROPBRTY/BUSINESS OWNER 13 OPERATORIMANAGER ❑ OTHER AUTHORIZED,'.0 NT[1[`� Fi PI1(pSC.CI'1C]}l Y't') . <br /> J,ffAPPLICANT is not the BILLINGPARTY proof of authorization to sign Is real; re <br /> a Tirtc <br /> AUTHORIZATION TO RELEASE INFORNLATION: When applicable, I,the owner I operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical d Is and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon s it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: K ) q ) RF MF <br /> /q,QU <br /> egC00 <br /> NA�P4e N/y <br /> ACCEPTED BY: i EMPLOYEE#: _ DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If a ready completed): SERVICECI:DI 1 ct P t E: <br /> Fee Amount: .�C� v Amount Paid 1 -510 — DI yment Date f Q <br /> _ I <br /> Payment Type S�- Involce# Check# A- Slg2Lfi Received By: <br /> EHD 48-02.028 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> OCT 2 9 2014 <br /> ENVIRONMENTAL HEALTH <br /> EPARTMENT <br />