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SAN JOAQT' COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 <br /> � 4 <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS[] <br /> Tot IM42K Cor• P"'o N+r 5 L LG <br /> FACILITY NAME <br /> MOOIJT1111640o�S e p t,� <br /> SITEADDRESS A�rc(GIKvDnr(�JW 46�� AR►J&.UbO 8RO5; Code <br /> L <br /> �^.7 Stteel Number Direction Street Name C' <br /> ty <br /> HOME or MAILING ADDRESS (If Different from Site Address) j'� <br /> 3LLQ_ To 4.6. 115L0 Street Number 5 • _ Street Name <br /> CITY STATE ZIP <br /> ✓ -3 <br /> PHONE#1 Ems' APN# LAND USE APPLICATION# <br /> (201) 836- Iv'0 ' 209-o40- omS <br /> PHONE#2 Ext BOS DISTRICT C LOCATION'ODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR . CHECK if BILLING ADDRESS`�-• <br /> FFAx <br /> E# Ex . <br /> BUSINESS NAME CC«►Da v�..HOME Or MAILING ADDRESS f <br /> 1" rLway. yJ cIQCIE S ) 234 -053 <br /> STATE ZIP ZCG <br /> Cm' STOL\LTo/J GA <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 thus projector <br /> activity will be billed to me or my business as identified on this form. 3 - <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SANT JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE.and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Ply_ ^ 100', am DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NLANAGER ❑ OTHER AUTHORIZED ANENTP <br /> Co.t u�Ta>JT <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. L�J l5(,L, C�-1 F_E4L_ <br /> TYPE OF SERVICE QUESTED: QEVt6H/ vA tt11��,_.rr_0 2.as E AN .*oP 1t ��'Jw '1•s <br /> �R AA11e.J0u 0". *1 046- Obl 61pg .J(u-L) Ct.o�.Ida /►n1� <br /> Co� �3 ops 1»a6 wJZ�cV.� sr-�.rErticrJt Or wa« c,.4.101y 6 4�kA.&J E� <br /> Wl� cColo <br /> N JOP00\,A EN-(MENj <br /> ACCEPtlV�n� EMPLOYEE#: 3 Z DATE: <br /> �� �1 L�� 0 <br /> ASSIGNED TO: EMPLOYEEM C)C-I( DATE: i'- -3 -s <br /> SERVICE CO <br /> Date Service Completed (if already completed): -9✓/9f <br /> DE: S ZZ- PIE: c 3 G l <br /> Fee Amount: ' r kiz. co Amount Paid 91"_o <br /> Payment Date 3'Ci S <br /> Payment Type - Invoice# Check# Received By: � . <br /> SR FORM(Golden Rod) <br /> END 48-02-025 <br /> REVISED 1111712003 <br />