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Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5 iZ, 007 Si c!' CIO -Fy <br />Cm( <br />PHON <br />( 14 3 4 -2 573 <br />OWNER OPERATOR <br /> Jose. GIV,k_ <br />FACILITY NAME . <br />&A w <br /> esss <br />SITE ADDRESS 5 - ) 1 S!reet Number Directio fltar <br />. 0; MAILING ADDF:1- S (If Different from Site Address) <br />5 1 2-5 -SaLy rive y\ 1--o <br />PHONE #2 fTXT <br />) <br />BOS DISTRICT LOCATION CODE <br />STATE <br />C CE2— 41— <br />LAND USE APPLICATION # <br />CHECK if BILLING ADDt:LT a _I <br />ULCJL rY_cLA <br />:itreet Name 5 htreei: Number <br />STATE <br />(A CITY ori ZIP 5 (f <br />HOME Or MAILINr, ADDRESS, <br />1 5 L 5 <br />Fax # <br />( ) <br />CHECK if BILLING ADDRESS E. <br />PHONE # <br />(tan 51 1 <br />EXT. <br />REQUESTOR <br />BUSINESS NAME <br />Lc <br />SAN JOAQUIN C. JNTY ENVIRONMENTAL HEALTH DEPA,. I MENT <br />SERVICE REQUEST <br />CONTPACMc. / iERVICE REQUESTOR <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 Of <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, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 <br /> <br />DATE: <br /> <br />OR-tMND OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at The ab--)ve <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same PAviviefer to me or <br />my representative. <br />ric.11/4,..c a w o-la <br />TYPE OF SERVICE REQUESTED: F9' \1e/11'CA e T-fic,ft.c,t-fini JUN 2 4 2016 COMMENTS: <br />SAN JOAUUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEP1 :D BY: EMPLOYEE #: DATE 001 to <br />ASSIGNED TO: NI\I EMPLOYEE #: DATE: (opt/ ip <br />Date Service Completed (if already completed): d SERWT .:,'ODE: (13cc2 I P 1E: 1k403 <br />Fee Amount: 9:).c31) Amount Paid \ -3 0 • cT (-2 iiment Date („i/2c1 <br />Payment Type /- c)/1 Invoice # Check # Received y: 2x—=-5- <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)