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JAN JOAQUIN I.OUN'IN r NVIRONMEN'IAL nEAL-111 1JEPARTMEN'I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ads <br /> OWNER OPERATOR _" I�f <br /> -f OY� } ryJ OE•yt�1 A 01-4 SI�I I?-11, CHECK If BILLING ADDRESS iCt <br /> FACILITY NAME (2LI\1E1(?-0% PILOPERTV <br /> SITE ADDRESS It'14S N • AAy 9D. (_Obl CIS2r{Z <br /> StraM Number treat Name <br /> CIW ZiD Code <br /> HOME or MAILING ADDRESS IN Dltferent from Site Address) <br /> I D11 (LErvOwN V(z• <br /> Street Number Street Name <br /> Cm TgACy STATE CA ZIP q s 3-1-(v <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> (U01 ) 97-0-(0429 oI1 - I (no -Lf-0 Ppt - 11000*53 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> (20 n) 4-1-"0- 7-532- 1 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR AM3 4 <br /> l:C Q CHECK If BILLING ADDRESS <br /> BUSINESS NAME l-1JE OfkK- GE:t7 E,r•�v�tLar�mt=Nrp.� PHONE# Er' <br /> HOME Or MAILING ADDRESS40'* vi 0*lL ST. <br /> FA%# <br /> CITY L Q0 1 STATE GA ZIP OI S 7-40 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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 JOAQUON <br /> CooNrY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: AA, A�a DATE: I-L <br /> PROPERTY/BUSINESS OWNER OPERATORAAANAGER ❑ OTHER AUTHORIZED AGENT P CorSVL-rttTJ-r <br /> ifAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Tine <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 environmentaUsite assessment <br /> information to the SAN JoAQuIN CDHNTY ENviRDNMENTAL 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: R-GV(EkJ SO i t` SO ITAF3I L I-f y 3T'V Dy <br /> COMMENTS: i�S�tz PAYMENT <br /> ��a2� l2e�te�c-G3 RECEIVED <br /> DEC 2 8 2011 <br /> SAN JDAQUN COUNTY <br /> II/ J ENVIRONMENTAL <br /> HEALTH OEPARTyp(r <br /> ACCEPTED BY: LV wer EMPLOYEE#: �S,t� DATE: 2-k I <br /> ASSIGNED TO: S EMPLOYEE#: d S_ DATE: f2-17-911 <br /> Date Service Completed N already Completed): SERVICE CODE: S Z Z P i E:J G p/ <br /> Fee Amount: '�-5D eo Amount Paid v'7��� Payment Date <br /> Payment Type u Invoice# Check# 5�l Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />