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SAN JOAA COUNTY ENVIRONMENTAL HEALTDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> serv � S � <br /> iGj� ��' D0/2530 IZ53z <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME /'I_ -,,roy-) c _,,L o` L 4 ?—�Oq�(I V7 y_ <br /> `ITEADDRESS Y®�ef n I' , �enu ei ►V IQn e ct R5 no <br /> 3 Street Number irection tre t m CIt Zio Code <br /> Hon or MAJUNG ADDRESS (If Different from Site Address) (cool D l l( � /an ^K 1�/ <br /> rvtiyiyv�Q�� l3treWet umber C�t.� t (�me[ N , CII <br /> clTr�V1 Rn rn on sex zip <br /> PHONE#1T APN# LAND USE APPLICATION# <br /> tf,) 9�z• q vo v Z 2 f Z Ool (o <br /> PHONE#2 EXT. BOS DISTRICT LocATI7 CODE <br /> 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> Gtr®►., R ® ,II <br /> BUSINESS NAME PHONE# ExT• <br /> v � t��r l vti <br /> HOME or MING DDRE&, FAX# <br /> WV-VT W�k .(�.� ( <br /> CITY swkA <br /> Ojiri/ STATE CP 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 HLALTII DEPARTMLN I hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,Standar , TA]F and FED[RAI. S. <br /> APPLICANT'S SIGNATURE: /GI!�6' / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M,\NAGER ❑ OTHER AUTHORIZED AGENT)� — <br /> IfAPPLICANT is not the BlaING PARTI',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 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. �+ I A <br /> TYPE OF SERVICE REQUESTED: �'®I p4-A Y-4- • (v'®VI 1 ✓1 `'l <br /> CommWICTEIVED <br /> APR 15 2015 APR 15 205 <br /> SAN JOAQUFN COUNTY ENVIRONMENTAL HEALTH <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT PERMITSERVICIES <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: q• <br /> Date Service Completed (it already completed): SERVICE CODE: PIE: �j© <br /> Fee Amount: a— Amount Pal 3 6D Payment Date X <br /> Payment Type Invoice# Check# 367 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />