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flEQEIVED <br /> NOV 2 4 2015 <br /> ENVIRONMENTAL HEALTH SAID JOAQuuv COUNTY ENWRON WNTAL HEALTH DEPARTMENT <br /> PERMIT/SERVICES <br /> SERVICE REQUEST <br /> Type of Business or P,r`o�perty � D �^FACIUT��F SERVICE REQUEST# <br /> OWNER(OPERATOR Q���.h -i , 7 c�� �yCHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> '� Ltir (!� <br /> SITE ADDRESS <br /> SVt <br /> Street umber a tion Stree a Cit Zi Cade <br /> Hon or MAILING ADDRESS (If Different from Site Address) <br /> SlreetNumbor Street Name <br /> CITY STATESE`\ ZIP <br /> P ONE M Z I APN# LAND USE APPLICATION# <br /> M C. <br /> PHONE#2 cm 1 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECKII BILLING ADDRESS11 i <br /> BUSINESS NAME jar' n — y4,;E C- C^„JPU ` C;E NC P E# <br /> HOME or MAI LI G ADDRESSF # <br /> 4f"�-) <br /> CITY I �i�T" _ STATE C6_ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized age—nit of Same, <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DSPARTMF,NT 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 the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COIJNTY Ordinance Codes,Standards,STATE and ,O s <br /> APPLICANT'S SIGNA +. DATE: `t <br /> PROPERTYIBUSINJ,SSOIYNFR❑ OPERATORIMANAGER N1 OTHER AUTHOR] DACF,NT Q <br /> /fAPPLICAA'T is not the 131/LINQ PAR71 proof of auth iZation to sign is required Tirls <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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTmFNT 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: PAYMENT <br /> RECEIVED <br /> NO V•L 4 2015 <br /> AA A'a N CONN <br /> ACCEPTED BY: EMPLOYEE#: DATE: �t/ <br /> O ENTAL <br /> ASSIGNED TO: �„�c .�2 EMPLOYEE#: DATE:, ULFARTMEN <br /> 921 <br /> Date Service Completed (if already completed): SERVICECODE: P E: , <br /> Fee Amount: 39O_(>C) Amount Paid 3 Payment Date (I <br /> Payment Type Invoice# Check# Received By: <br /> EHO 48-02-025 0�Z V 13 SR FORMIGolden Rod) <br /> REVISED 11/17/2003 i 1 'ZQ/1 <br />