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v al11 A l J`11 T 1nv111Tlr1ly 1 AL rlr AL In JJEFAK 1 INIE'NT <br />.Type of Business or Property -'IIP'-- <br />OWNER <br />'IIP'—OWNER / OPERATOR <br />FACILITY NAME <br />SITE ADDRESS C, A <br />SERVICE REQUEST <br />�j� FACILITY?ID # <br />� " _ 1 -3 <br />Street Number Direction <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />CIN <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS O <br />(A <br />— Civ Zip Code <br />s <br />Street Name <br />STATE ZIP <br />PHONE A APN # LAND USE APPLICATION # <br />l ) � 7 _ 2,00.0 � <br />PHONE #2 ExT. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Ht CHECK if BILLING ADDRESS <br />BUSINESS NAME ,, P EXT. <br />HOME or MAILING ADDRESS1� `� ~ <br />✓ �/ � W 1 F # t4 bJ �O -1 d� <br />CITY <. STATE <br />_ ZIP <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 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, Standards, STATE and FEDERAL law <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR/ <br />MANAGER O. ER AUTHORIZED AGENT <br />- If APPLICANT is not the BILLLVGPAR7Y 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 <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. <br />TYPE OF SERVICE REQUESTED:S ?' "� \ , C r,\ -. N <br />CommENTs: <br />ACCEPTED BY: O L I VIE( <br />— <br />ASSIGNED TO: (2A <br />Date Service Completed (if already completed): <br />__.. F A <br />EMPLOYEE #: © 3 <br />EMPLOYEE #. l , <br />SERVICE CODE: <br />ee mount. • Amount Paid <br />Payment Type Invoice # Check # L <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />PAYM ENS -A <br />RECEIVED <br />AUG 1 1 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL I""ENT <br />DATE: <br />DATE: NlillO <br />g�- PIE:U <br />Payment Date g <br />0 <br />*t) QfIuY7 of4ri'Rod) T <br />