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L3P-rl v VEil1 U ilr V V U 1! 1 E 1 tisu l e r, &LA+i ti A <br />Type of B iness or Pro erty <br />BUSINESS NAME <br />Lae - <br />FACIIITY ID # <br />; ::_: <br />SERVICE REQUEST # <br />CITY STATE ZIP r—� <br />Comm ms: <br />OWNER / ERATOR <br />AUG 2 3 <br />CHECK If BILLING ADDRESS <br />� <br />FACILITY NAME <br />SITE ADDRESS ^X�Af�' <br />p PAR <br />6�/y <br />(A' �e <br />6 Street Number ; Direction <br />StAug/j, <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />ASSIGNED TO: <br />CCCC <br />^ree <br />7 <br />Street Number <br />Date Service Completed (if already completed): <br />Naa <br />CITY <br />TATE ZIP <br />S#11� EXT. <br />PHONE <br />(,% <br />v/ — 737f-, <br />APN # <br />LAND USE APPLICATION # <br />Exr. <br />cam" °G, 702 — Ofd" 2 <br />Date Ell 0 <br />BOS' DISTRICT <br />LOCKH N CODE <br />REQUESTOR a CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Lae - <br />N NE <br />PN <br />HOME or MAILING AD RE S <br />FAX # ,y <br />CITY STATE ZIP r—� <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 this form <br />I also certify that I have prepared this application an the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F E laws. <br />APPLICANT'S SIGNATURE: DA AVe�02 3 7— <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER 0, OTHER AUTHORIZED AGENT <br />IfAPPLICANT is not the BILLING PARTY, 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 />nrnvitip-A to me nr my representative. <br />TYPE OF SERVICE REQUESTED: <br />PAY <br />CES eb <br />Comm ms: <br />AUG 2 3 <br />2007 <br />SAN J'RONM COUNTY <br />HEALTH TAL <br />p PAR <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P ! E: <br />Fee Amount: Z tJa <br />Amount Paid <br />Paymen <br />Date Ell 0 <br />Payment Type <br />invoice # <br />Check # ZA IL <br />Received <br />EHD 48-02-025 --._. °,,�:�.. _... ..- <br />REVISED 11/17/2003 <br />