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SAN JOAQUPP OUNTY ENVIRONMENTAL HEALTF —EPARTMENT <br /> SERVIC-9 "QUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> Ciatc�l/> f>ilL /�reY /l�/(S LCHECK It BILLING ADDRESS <br /> FACILITY NAME /}/ L /� <br /> SIT�An�sDDRESS Ar, �6l 'SOS? 2(� CiP ®L% S `/SGZ 7 <br /> Street Number Direction Street Name CI Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number St eet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCA ON CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // e✓ ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME\ /—c GC PHONE# EXT. <br /> Agovt/ (yar�/ Ze/7 Lt.S5lc494( 0-134f5- <br /> HOME Or MAILING ADDRESS 28 ZS G r /�'l y P' 'e E f" (FAx# ) eve --ObZ <br /> CITY j` STATE ZIP <br /> BILLING ACYNOWLEDGEMENT: 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 projector <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,S ATE and FEDERAL laws. /- <br /> APPLICANT'S SIGNATURE: —"' ,�/��e&f DATE,: /�Z�D 1{�V 3 <br /> PROPERTY/BUSINESS OWNER❑ • OPERATOR/N1 NAGER ❑ OTHER AUTHORIZED AGENT 2 <br /> IfAPPLICANT 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: 15 ZX, \ <br /> COMMENTS: RECEIU D <br /> ��cc�yyn DEC - 42003 <br /> !'tCls-t,> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HFAITH P FITMENT <br /> ACCEPTED BY: _ EMPLOYEE#: / DATE: <br /> ASSIGNEDTO: EMPLOYEE#: S DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE: d <br /> Fee Amount: Amount Paid ;,> Payment Date <br /> Payment Type 1– Invoice# Check# - Received By: <br /> EHO 48-02-025 SR FORM <br /> REVISED 11/17/2003 - - J <br />