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PPW- RRC ENED <br /> SAN JOAQUIN OUNTYENVIRONMENTAL HEALTHAPARTMENT <br /> N w NOV - 9 2006 <br /> i <br /> Type of Business or Property FACILITY ID# SE RENNAW HEALI H <br /> tw <br /> VveV- UVO-6 / Y7 / SRO S E�MtT/SERVICES <br /> OWNER/OPERATOR <br /> \�Q CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> L4 <br /> S�— <br /> Street Number Direction Street Name Ci „'V l Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) �y V <br /> i2- <br /> Street Number reef Name <br /> CITY „ p� STATE � 7/) ZIP Q <br /> PHONE#1 ExT• APN# LAND USE/(APPLICATION# t <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V)—�u <br /> T Y F U u�t.K� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> �aI-]ILI L43 I-q I L-(6 <br /> HOMEorGADDRESS FAX# <br /> MAILINe5 V"R[ r USW I�Iud cl I ) 5 S <br /> CITY STATE fA. ZIP G� <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 <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 FE ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: !l Q <br /> PROPERTY/BUSINESS OWNER❑ OPE� TOR/MANAGER ❑ruthotion <br /> ER AUTHORIZED AGENT I� <br /> If APPLICANT is not the BI LING PARTY,proof of to sign is require Title <br /> AUTHQRIZATIQN TQ RELEA E IN RMATIQN: 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: , (?�z�ctC �yt,a _ C <br /> COMMENTS: NOV 0 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: (/,or JW-,L9 DATE: <br /> ASSIGNED TO: &Aq34'c, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 Q,p P/E: <br /> Fee Amount: Amount Paid �2-g S" , BO Payment Date <br /> Payment Type Invoice# Check# 3-7,7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />