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REQUESTOR R(Ai( ou 14,1 j)r lqacio 3 <br /> przthi 0010 ( <br />HOME or MAILING ADDRESS <br />crcl) Lk e:61 beyke 1 a yLi, <br />CHECK if BILLING ADDRESS la. <br />BUSINESS NAME PHONE # <br /> EXT. <br />Fax <br />( ) <br />CITY ykock.zisi....0 STATE ZIP 'S T317 <br /> <br />SAN JOAPPCOUNTY ENVIRONMENTAL HEALMARTM ENT <br />SERVICE REQUEST <br />Type of Business or Property <br />c-)a)cAL( <br />FACILITY ID # <br />FA 000 6 cti7 <br />SERVICE REQUEST # <br />OWNER! OPERATOR <br />c;\ .3v()14-,1[u ') e I,- ( L. OLS <br />CHECK if BILLING ADDRESS Er <br />, , ,- FACILITY NAME ‘ ji <br />CVC D \--- \ IS rOcA_uce - V <br />SITE ADDRESS <br />umber Direction <br />—\ DO raOLC S k. ' <br />Street Name CrOL --01A City <br />GI 5 iOLP <br />Do Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />'K u-1 Street Number foii ell I ecfc (c " .e Street Name <br />Crry STATE ZIP <br />PHONE #.1 EXT. <br />(109) 1qq <br />APN # <br />1 (:16700 5 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE 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: er (2 , Alerzep*ATE: (2/1 VII <br />PROPERTY! BUSINESS OWNERb'- OPERATOR! MANAGER 0 //.. OTHER AUTHORIZED AGENT 0 <br />/f APPLICANT iS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: i--.00& 60 in 4--)LAt -47A t 3" PAYMENT <br />COMMENTS: L.1 e_ 0 f- C) WM", RECEIVED <br />OEC 1 5 2017 <br />SAN JOAQUIN COUNT( <br />ENVIRONMENTAL <br />I-TALTH DEPARTMENT <br />UATE: I ), -.1 5_ 1 7 ACCEPTED BY: f\--101/4./- t o t-eitcA, EMPLOYEE #: <br />ASSIGNED TO: til k Nip\ EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: j (...7 P/E: [ , <br />Fee Amount: i [51, (170 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />Title <br />EH D 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)