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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE ,QUEST AML <br /> Type of Business or Property -FACILITY ID# SERVICE REQUEST# <br /> Do 5 1 <br /> OWNER/OPE OR <br /> i CHECK if BILLING ADDRESS- <br /> FACILITY NAME <br /> SITE ADDRESS'32_Z W � C?S q V E, L�i��P ?-S 3 3 p <br /> Street Number /Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 9x( 09 2—LA 2,?© —cam z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) (_�I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> jj CHECK if BILLING ADDRESSEI <br /> BUSINESS NAME PHONE# EXT. <br /> j <br /> HOME Or MAILING ADDRESS FAX# Q _ <br /> b Y' Y'. (�Ci )(9 <br /> CITY \ STATE C-A ZIP <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 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /�, , DATE: Z©,7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER U OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 /> provided to me or my representative. PqY{ <br /> TYPE OF SERVICE REQUESTED: h �1 E'1 VED <br /> -.;7-COMMENTS: vlr5 �i X07 PR 4+ <br /> � l v 2007 <br /> S EN IFiPUI N COUNTY <br /> HFALTH p AE �� <br /> ACCEPTED BY: A,.__. EMPLOYEE#: 3 Q"7Z DATE: <br /> ASSIGNED TO: � � G 1EMPLOYEE#: q-7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CZ-Z' P I E: 'Nb 2 <br /> Fee Amount: �qo so Amount Paid A Payment Date LA <br /> Payment Type U t(;I Invoice# Check# Received By: <br /> EHD 48-02-025 Q '�` ,S'R F(2RN1(Golden Rod) <br /> REVISED 11/17/2003 <br />