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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE BEQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> C;lEC:;ifBILLIHG.4 r•. =SSL „ <br /> � Faclurv' 'AME — -- — - -- — --- — - --- — - <br /> SITE ADDRESS <br /> _.�._.__.._. Stree!N-mber ,—D!r�c na?Ion Street .__. ...._,—.__. .—.. Lq .. <br /> I '(VIE U <br /> MA,! AG. 2F-,5 (Pi Diffr rent from Site Addre:a; �' <br /> _ _t I•lum-.:ar l~ Str1'eet Name _ <br /> F.'HI <br /> ITY a��` STATE -4 ZIP C / <br /> Y --a --� <br /> NF#1 EXT. APM# — I LAND USE APPLICATION�# <br /> PHONE#2 EXT. BO` .";STRICT ( 'A—ON C(—. - <br /> _ <br /> CONTRACTOR/ SERVYC�: R ;Q(1ES"TOR _ I <br /> R 'QUESTOP. II CHECK if B:LLING ADDRE_,5 <br /> BUSINESS NAME PHONE# �� <br /> EXT. <br /> ✓� o LCA2 r e o <br /> HOME or MAILING ADDRESS n FAX# <br /> ,;Z So San i(�(���Po A/P-. <br /> CITY STATE ZIP <br /> BIL!IVIG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sarne, <br /> e:imoWledge 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, StO-ndards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUIIE: C£-�=-� _ -/' 1�/� DATE <br /> PROPERTY/BUSINESS OWNER 1:1E OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLY,-ANT IS not the BILLING PARTY,proof of authorization to sign is required Tire <br /> AU,"IORIZATION TO RELEASE INFORMATION: When applic.a:le, I the owner or operator of the property locatad at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAOUIN COUNTY ENVIF'ONMFNTAL HEALTH DEPARTMEN-as Soon as it Is available and at the Sam.-time It Is provided to mP .�r <br /> my representzt`ve. <br /> TvPF 01 SERVICE REQUESTED: �� P L2 l 00 —, pA NT <br /> COMMENTS: <br /> MAR 14 2016 <br /> .jTy <br /> SAN JOAOUIN COU <br /> 14 <br /> ENVIRONMENTAL <br /> JJEALIA1 DF-PAR TIAL-NT <br /> AC-EPTED B',- Q -- _ EMPLOYEE#: — — DA;::: <br /> ASSIGNED TO: ( "�S� I l� EMPLOYEE#: — DATE: <br /> Date Service Complete(: (ifalread completed): - Sr:VI;-' 'BODE: l 1'I <br /> Fee Amr, Int: �-� Amount P,1d P� ayment Date <br /> Payment Type invoice# Check# Received By: 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />