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JAN JOAQUIN W-OUN'1'Y ENVIRONME'N'TAL MALI 101;PARJ'MLI'NJ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 053-7C� <br /> OWNER/OPERATOR <br /> �E,NNI S Gft�DE1MEy� � ZV�-k6(z Y✓��tN MNNI*�E\)I LL-E CHECK If BILLING ADDRESS® <br /> FACILITY NAME 7L)c ILEYz-rrlRn/ yvl/kn1DEVlL-LC P120PEP-Ty <br /> SITE ADDRESS tllf,,J , ZVLILra2rYLAN (L>. ST -,Y-T-0�1 <br /> St.t Number Dlrec5on tree[Name chy e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) O . B OX 9} <br /> Street Number Street Name <br /> CITY LlLTOr�I STATE CP\ ZIP 9 �Z�1 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> I?-Oq ) 4u1i - 9 129 - 090I j2p,1z0010-2- <br /> P14ONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR v <br /> RSB 1 2 pcCC O CHECK If BILLING ADDRESS <br /> BUSINESS NAME l-IJC O"- GtUE:NJI P-uNfvlt:IvfW l_ PHONE# EaT. <br /> 209 3l0`1- 03'1S <br /> HOME Or MAILING ADDRESS '4O-4 W ORS S„` FAx# 02)'x'4 <br /> CITY t-OT-�t STATE CA ZIP <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 /> also certify that 1 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. <br /> APPLICANT'S SIGNATURE: eA o DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER 13OTHER AUTHORIZED AGENT 10 C/NSVLTW'+VT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. ffAYIVIENT <br /> TYPE of SERVICE REo1EsTED: "VIEvJ S01L, SVIT^31L- I" RECEIVED <br /> Comma ts` 9/0 (ivJUL 2 0 2012 <br /> T 7�z� /� <br /> � ` <br /> In-In-,e LSO <br /> . / t ENVIRONIME COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE DATE: r/ - ��Z <br /> ASSIGNED TO' CO /L)125 EMPLOYEE#: DATE: <br /> Data Service Completed (M already completed): SERVICE CODE: PIE: D <br /> Fee Amount: agf6Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />