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' Feb 1'7 12 08:15a Reliable Petiole 2 45-8953 p.3 <br />S JOAQUSOUIXTY ENVIRON_VIE\-TAL HEAL EPARTNIENT <br />SERVICE RF0TTF.qT <br />Type of Business or Property <br />1-k puk 11 J 1 pS,�� <br />FACILITY ID # <br />SERVICE REQUEST # <br />S -e j,,. C) I^ A' -7 q q :j T-0-- ZO L3, <br />PAY MERT— <br />OWNER i OPERATOR <br />l� <br />�} <br />J" t (�k �(� <br />CHECK If BI LUNG ADDRESS L� <br />FEB 2 2 201 <br />FACILITY NAME .t t+ <br />�0_ <br />f\ <br />�� ��/ <br />SITE ADDRESS -i 7�' <br />Street Nu <br />t� <br />{Direction <br />I } I' L S 0 �/I �`� <br />W <br />U <br />%� <br />+ dLt} <br />ber <br />Street Name <br />Z <br />CI 7ie Code <br />HOME or MAILING ADDRESS <br />f Different from Site Address) <br />PIE: 23ag <br />Fee Amount: jr,40, <br />Street Number <br />Street Name <br />CITY <br />Payment Type Vi -;;,A <br />STATE ZIP <br />PHONE qj-t <br />( C) t. <br />Received Elly: <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOGATION :ODE <br />C.;(YNTRAUTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECKifBILLING ADDRESSQ <br />BUSINESS NAMEEXT. <br />o" <br />vlettrri SerCePHONE# <br />3 znc, NE , <br />HOME or MAILING ADDRESE FAX # <br />I 1 0 �fvrses)-lug'. ?A , 00�, gtis- �es3 <br />CITY <br />4/ (�-.. Q jC J0 -j p / <br />I ` 1...- STATE C Ji ZIP <br />BILGING ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all siteand/or project specific ENVlRON4IENTAL HEALTH DEPARTMCNT hourly charges associated with this project <br />or activity wil I be billed to me or my business as identified on this form. <br />I also certify that l have pr pared 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. I <br />APPLICANT'S SIGN.AT RE: DATE:— <br />F'Rl?PERTY / BUSINESS Z)GtiNf i ❑ OPERATOR/11'IAt\AGI R ❑ OTHER AL'fHQR[ZED AGF,NT CA r" <br />If fl PPLIC.4,1 is not the BILLI.•VG P:ll?T proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: 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 environtnentalrsite assessment <br />m <br />inforation 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 retire entative. <br />TYPE OF SERVICE REQUESTED: <br />1-k puk 11 J 1 pS,�� <br />�✓i <br />COMMENTS: <br />S -e j,,. C) I^ A' -7 q q :j T-0-- ZO L3, <br />PAY MERT— <br />RECEIVED <br />FEB 2 2 201 <br />sAN JOAQUIN CDU <br />EWRONMENT <br />ACCEPTED BY:tv((% <br />EMPLOYEE #: <br />�� ��/ <br />HEALTH DEPA.RTM <br />DATE: Z <br />ASSIGNED TO: O Opc. <br />71 EMPLOYEE #: <br />U <br />DATE; <br />Z <br />Date Service Completed (IF already completed): <br />SERVICE CODE: <br />(� <br />PIE: 23ag <br />Fee Amount: jr,40, <br />Amount Paid <br />-J <br />Payment Date <br />Payment Type Vi -;;,A <br />Invoice # <br />Check # <br />Received Elly: <br />n <br />EHD 48-02-025Lei4%11) 7 6 <br />REVISED 11117/2003 , SR FORM (Golden Rod) <br />Y <br />I <br />