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-Type of Business or Property <br />OWN`ER/ OPERATO,(n <br />FACILITY NAME <br />SITE ADDRESS a V <br />"A A ui� rinvt�trlr�lvlAL IIl'AL1ti 1115YAK11V1L1VT <br />SERVICE REQUEST twL <br />FACILITY ID # <br />S�- 9 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />PHONE #1 <br />( ) <br />PHONE #2 <br />REQUESTOR <br />BUSINESS NAME <br />HOME or MAILING ADDRESS <br />CITY <br />EXT. <br />EXT. <br />103- i3U- 07 <br />SERVICE REQUEST # <br />4QTjq-5'39 <br />CHECK if BILLING ADDRESS D <br />LAND USE APPLICATION # <br />BOS DISTRICT II LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING A[ <br />STATE (' A- ZIP <br />1,o75Lua. <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 1 WS. <br />� A <br />APPLICANT'S SIGNATURE: DATE: F�-- 0 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER D. ER AUTHORIZED AGENT <br />- IfAPPL1C.ANT isnot theBILLZNGPARTY Proof of authorization to sign is reguir Tule <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 environmentaYsite 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: L4 's I MENT P <br />COMMENTS: RE <br />MAR 8 2010 MAR <br />SAN JOAClUIN COUNISAN JORONN `' 1U�Y <br />ENVIRONME TIAL lji�TM DEP. <br />H�Tti DEPAR <br />ACCEPTED BY: o L k") E i <br />ASSIGNED TO: Fe j V p <br />Date Service Completed (if already completed): <br />Fee Amount: 3 L( S. rF Amount Paid <br />Payment Type Invoice # <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />EMPLOYEE #: ,C) 3 -2 i <br />EMPLOYEE M <br />SERVICE CODE: �' G �Y <br />5 — Payment Date <br />Check # 5 l 1 <br />DATE: .3/ <br />I f o <br />DATE: t f r O <br />PIE: <br />Received By: W; `S_ <br />