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SAN ONMENTAL HEALTH ENT <br /> CE REQUEST ' <br /> Type of Business or Property JAN 16--'2015 FACIUTY ID# SERVICE REQUEST# <br /> OWNER/OPERATORN 11GPARTAAFNT CHECK If BILLING ADDRESS❑ <br /> ��m NFA!T <br /> FACILITY NAME c-. T k <br /> SITE ADDRESS <br /> 21 � ` .)1�CtsE`) <br /> Street Number 'Direction Street Name CI Zho Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) + <br /> Street Number Street Nge <br /> CIT. STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT <br /> LOCATIONCODE <br /> e� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR a CMECK If BILLING ADDRESS <br /> BUSINESS NAME r PH E Ext. <br /> HOME or MAILING ADDRESS� C FAX# A <br /> OWAIPM R% ( ) <br /> CITY '15T6MU n <br /> STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMLNT hourly charges associated with this project <br /> g <br /> or 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 Coders,Standards,STATE and.FEDERAL laws. <br /> APPLICANT'S SIGNATURE: - ( Im DATE: pi Y4, <br /> _ }� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEREI OTHER AUTHORIZED AGENT� ¢ � �'T if ' <br /> IfAPPLiCANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATIQN: When applicable,1,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: • �� r ( T <br /> r <br /> COMMENTS: <br /> JAN 16 20,, <br /> NEA�o OMEN�V TY <br /> H pEpaRT�E <br /> T <br /> ACCEPTED BY: ` EMPLOYEE M DATE: t ILI <br /> ASSIGNED TO: tA h r EMPLOYEE M DATE: <br /> Date Service Completed (if acredy Completed): SERVICE CODE: c( P JE: '2 3 e3 <br /> Fee Amount: CIO ` Amount Paid �39 D _ Payment Date <br /> Payment Type 5A_., Invoice# Check#&Xf; 414,116 O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />