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NANJOAQUIN UOUNTY. vJWNTAL riEAL'IH1)EPARLMEN1 <br /> SERVltz "QUEST <br /> Type of Business or Property FACILIT'r ID# SERVICE REQUEST# <br /> 1J,N<�taR� Shoo 4 `13q `f <br /> OWNER/ OPERATOR <br /> K U S ^'`/ ) I SC r VA <br /> Q CHECK If BILLING ADDRESS <br /> FACILITY NAME \//SIA Lw-x/',�/IL)CL1A2b-S IJ J <br /> SITE ADDRESS M Ac i,-\J I L,L E R oAb <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6 <br /> 2/nC� <br /> I Street Number GE-lE Street Nam. <br /> CITY D STATE ca ZIP �_ Q <br /> PHONE#1 ExT' APN# LAND USE AP LICATI # <br /> � � <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> 11 4?P <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR P <br /> SC I-j CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> I<1SCFI 1 A' Q1M i..s I--"�q 6� - Gds <br /> HOME or MAILING ADDRESS FAx# <br /> 641 H&KTz RD ' (zoo) 3 <br /> Ll <br /> CITYL— J D I /1 STATE ZIP '�7 <br /> BILLING ACKNOFVLEDGEMENT: 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 this project Or <br /> 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 be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. J ? <br /> APPLICANT'S SIGNATURE: "to --z-- DATE: <br /> PROPERTY/BUSINESS OWNEXA OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <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 <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. <br /> TYPE OF SERVICE REQUESTED: (✓ PAYMENT <br /> REeEIVEB <br /> COMMENTS: <br /> rte , :, �� �6 .�_ . e► C JUL 13 2006 <br /> NTAL <br /> /`T C�'7.-'s)p.F�j�t-� AN JOAQUIN <br /> COUNTY <br /> ENV7' r7"le ' 1 HEALTH DEPARTMENT <br /> ACCEPTED BY: // EMP OYEE#: DATE: <br /> ASSIGNED TO: f+t EMPLOYEE#: DATE: ti- O10 <br /> / <br /> Date Service Completed (if already completed): SERVICECODE: �'jj7i PIE: <br /> Fee Amount: U` Amount Paid _ Pm <br /> ayent Date <br /> Payment Type Invoice# Check# Received By: s <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />