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SAN .TOA N COUNTY ENVIROM IIE.YTAL HEF--,,,r Ii DEPARTMENT <br /> SERVICEE, QJEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR) CHECK if BILLING ADDRE <br /> FACILITY NAME <br /> SITEADDRESS ®1N,L-� <br /> Street Number Direction L,r `-� _1 Street Name 1 x- C1i Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1, Street Numer fi.J V- <br /> I, <br /> Street Name <br /> CITY I I` �r© STATE oil- <br /> j� ZIP 5 6d ct <br /> PHONE#1 Il ExT. APN q LAND USE APPLICATION# <br /> u Cl <br /> PHONE#T ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ///111 <br /> CHECK If BILLING AODRESS <br /> BUSINESS NAME 11 V u 17J PWNE N IT, <br /> o 36 -X70 <br /> HOME or MAILING ADDRESS FAx# <br /> CITY / / STATE lr) ZIP C`ca <br /> 1 (�/�1 <br /> l/� l t <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 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 an�that w k to be perfomTed will be done in aecordance with all SAN JoAQUwCOUNTY Ordinance Codes,Standards,STATE and FE <br /> APPLICANT'S SIGNATU�RfE: DATE: <br /> PROPERTY t QLISINFsS OWNER lL1 OPEItAT MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> if APPLICANTT is not thea 1NG PARTY proof of authorization to sign is required Title <br /> 01 <br /> AUTFIORIZATION 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: <br /> COMMENTS: /�;�QS` '[YU[IP(vc�DG Il llr. Oe JOW(a <br /> o IloP , Pc`�� Se��'� 6dQC1(3 f►'1''�� I��SSl�s i '(�E_ )003 <br /> /�.<.... i� Bl I.A TRVIC.fT111-1Sf <br /> �� NF <br /> APPROVED BY: �i� �' ( EMPLOYEE#: "1 �/ DATE Ci — <br /> ASSIGNED TO: �Ii EMPLOYEE tf: !A 6 DATE: <br /> mcL <br /> Date Service Completed (if already completed): SERVICE CODE: 17 PIE: 2GC <br /> Fee Amount: 402 1Amount Paid /� Payment Date O� �25 <br /> Payment Tye Invoice# Check 43 lleceived By: � <br /> EHD 48-0 25 � �YGcJ .�+� _� SE VICE}2ECIUEST rORM� <br /> REVISED 6-5-O � /t om ✓ '� r�J <br />