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�- SAN JOAQUIN COUNTY <br /> pENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Y o Vl.a,71 o 2- Soo X 51 b <br /> OWNER IOPERATOR Mey'CAoAvy 0��f-c\CL <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f--f e <br /> v <br /> SITE A DRESS <br /> Street Number Direction N :freAFName- i COode <br /> NOME Or MAILING ADDRESS (If Different from Site Address) i—lza.ber <br /> i/�� 1)7Ee�t i7�me AY <br /> CITYSa ^ n TATE IP <br /> iP! , <br /> SP- q�� '?--'� 2, <br /> PHONE#11, ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CGDE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> L✓ � CHECK If BILLING ADDRESS13 <br /> BUSINESS NAME i�r C PHONE 1 — 6g <br /> ExT. <br /> 41 1 <br /> HOME or MAILwG ADDRESS FAX# <br /> Lary <br /> STATE ZIP <br /> BILLING ACKNOWLE€3GEf,{ENT: 1, 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. I <br /> I 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 FEDERA lgi4S. / I <br /> AFPLiI:AN I`S SIGNATURE: DATE: <br /> PROPERTY 1 BUSINESS OWNER. OPERATOR I MA ER [3OTHER AUTHORIZED AGENT ❑ <br /> If 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 environmentallsite assessment information <br /> to the SAN JOAQUIN CouNTY E=NVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to file or i <br /> my representative. <br /> TYPE OF SEP.VICE REQUESTED: PIAOXI <br /> COMMENTS: �} J ,� REGEIVD JUL 0 5 20% <br /> i/ `'[/!�}/�/ --J —M16—ENVIROWENTA!_HEALTH <br /> SAN JOAQUIN COUNTY PERMITISERVICES <br /> ENVIRONMENTAL <br /> HEALT`{Of?ARTM`e�'T <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: 5 EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: _ 166 <br /> Fee Amount: { L� U' Amount Paid 13(>,cr) Payment Date -7 <br /> Payment Type L c�S h Invoice# Check# Received By: <br /> RECEIVEDEHD 48.02-025 JUL 0 5 20% FORM(Golden Rod) <br /> 07117/08 <br /> IAN JOAC)NIN COALTY <br /> IiEALTH DEP <br />