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JAN JOAQUIN %-OUN'I Y ENV IRONMLI'N'I AL tILI'ALTti UIEPARI MLN I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SF-O0 -3 C <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> ,MiK�. + L15 A ZiCPF�\ <br /> FACILITY NAME Zl GP<<L� PizOPE1�Z V <br /> SITE ADDRESS 1., 11 N CDI�D 1Z�' C LtENTS -1 S ZZ� <br /> 41'5 �} 4 Number Di 'on Street Name C1W ZJP Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) (2 D, is oX 2 2-L4-O <br /> Sheat Number Street Name <br /> CITY L—6V <br /> STATE GVN ZIP y!�24 <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> (Le`I) 3o"53 13aoi33 <br /> PHDNE#2 En. BOS DISTRICT LOCATIj�yy++CODE <br /> I 1 004- <br /> CONTRACTOR <br /> biCONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR e. <br /> r,RO y "CGQ CHECK if BILLING ADDRESS <br /> ERT <br /> BUSINESS NAME L-4 Vt� UPAG- �EOQ�IJIR-0NN1ET/T 111. PHON <br /> Zo' 3(acl _ 03-45-- <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY L-ox-�I, STATE C h ZIP I S 3-.f O <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 ENvtRONMFNTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify,that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUtN <br /> CouNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �'�` DATE: 4(3- z9 - 13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AtrTHORIZED AGENT M LDL./f,/LT&W-r <br /> If APPLICANT 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 environntentaVsite assessment <br /> information to the SAN JoAQuTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tyle same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: IZt:V 1CoJ (;:OIL- SYrrkAI L-1"7i %TU�>�f C 4f <br /> lk- <br /> COMMENTS: Sq Zi O <br /> I I U K u t rte i/ /Zo%3 '1 110 '9 <br /> 1To hFq� h F Fq ry <br /> M6I,T <br /> ACCEPTED BY: M EMPLOYEE#: 7--C <br /> iW ) DATE: I t3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: --2&0 1 PIE: SZZ <br /> Fee Amount: Z Amount Paid ,256.o D Payment Date I D 3 <br /> Payment Type Ij Invoice# Check# 54�`%,',. Receive By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />