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77 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> s„ <br /> SERVICE REQUEST h, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 <br /> r n <br /> OWNER I OPERATOR x - <br /> Nlc,K, SPAlvn$ CHECK If BILLING ADoRESS❑' <br /> FACILITY NAME <br /> t.4 <br /> SITE ADDRESS 1-743,& W [� WPy Lt�r i-D�D 9'523 <br /> Street Number Direction Street Name city ZI Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) 31 0 iQ14A Dom/ XCZZ�S 21?- <br /> F' <br /> Street Number Street Name <br /> CITY LIOD STATE CAZIP S 24 - <br /> PHONE#1 EXT. APN# LAND USE APPLICATION <br /> (20q 60� -�. <br /> Ja <br /> PHONIER E t• BOS DISTRICT LOCATION CODE <br /> { I <br /> i <br /> CONTRACTOR f SERVICE REQUESTOR <br />! REQIlESTOR <br /> CHECK if BILLING ADDRESS <br /> �X f <br /> j� 5 6r fly <br /> BUSINESS NAME �. PHONE# 33 —��f � rr `. �^pssry • <br /> HOME or MAILING ADDRESSFAX# <br /> Z <br /> x 1 S t24Dq I Cr <br /> J > <br /> CITYSTATE: zip <br /> L CA <br /> OD I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent°bt same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated withthis project <br /> or activitywill be billed to me or m business as identified on this form. vr' <br /> Y <br /> I also cern that I have prepared this application and that the rk"to be erfanned will k <br /> a certify a p p pp o p be done in accordance with all SAN'Toa,Q[iN,,.,,,•,,.,:.,:;:,,<;.:.;,� i <br /> COUNTY Ordinance Codes,Standards,STATE and FTQERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: x <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY•proof of authorization to Sigh is required T}t1e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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.IOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time It <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: V ECE1V <br /> COMMENTS: <br /> F1 3 v2oo8 f <br /> �jData <br /> SAN JOAQUIr4 G <br /> ENVIVOIR�NME3-47A1- <br /> ti1rALTH1nPARSME <br /> ACCEPTED BY: 614JR <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: sZ /_- DATE: i <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> -'5W7 2, PIE: j <br /> Fee Amount: Amount Paid O, Payment Date L <br /> Payment Type Invoice# . Check.# s Received By: <br /> 1 <br /> EHD 45-02-025 SR FORM(Golden'Ro'd <br /> REVISED 11117/2003 <br />