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RECENED <br /> SAN JOAQUIPOUNTY ENVIRONMENTAL HEALTH MARTMENT <br /> NGV 9X006 <br /> Type of Business or Property FACILITY ID# $E1 HEAL H <br /> AZ\(VV V �•V�C� l ,/ �)�� RL ti SERVICES <br /> OWNER/OPERATOR j �J <br /> '\ e CHECK If BILLING ADDRESS <br /> FACILITY NAME l (/1/ <br /> SITE ADDRESS �2"Z 9 0 <br /> Street Number Direction T V Street Name Ci 1 ` ✓Zi CwodeV <br /> HOME or MAILING ADDRESS (If Different from Site Address) a-T ] V <br /> Street Number teat Name <br /> CITY STATE C,�/) ZIP (A <br /> PHONE#1 EXT. APN# LAND USE jAPPPLICATION# ! <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR cy 1n n/.1�X.v l <br /> U v CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> -1 4Lf �-t 31�. I C4�) <br /> HOME OrAILING ADDRESS FAX# <br /> 15 S V'1101 r v\� I�j�t/c� ( 11 ) 5�) - S <br /> CITY (!1 STATE �/Q ZIP 11 Z6 <br /> �p <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 DEPARTMENT hourly charges associated with this project <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 Codes,Standards, STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ruthorizadon <br /> THER AUTHORIZED AGENT <br /> If APPLICANT is not the BI LING PARTY,proof of to sign is require 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 /> provided to me or my representative. ' 1 i\3 E—J-! <br /> �1 e_ _. ._ <br /> TYPE OF SERVICE REQUESTED: �37K-llG NOVV(� <br /> COMMENTS: N � 2006 <br /> SAN JOAQUIN-COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �'/ Q e,�' j C��o !?, EMPLOYEE#: 4/.gr y DATE: -ll/l© ee <br /> ASSIGNED TO: /! zl-4 a'r ,� C1� EMPLOYEE#: z K 9-/J DATE: /1// <br /> Date Service Completed (if already completed): SERVICE CODE: 30-0 PIE: 4f4'0 7 <br /> Fee Amount: a Amount Paid 8 S" , QO Payment Date <br /> a <br /> Payment Type Invoice# Check# ,2 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />