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SAN JOAQUINfiT, ry ENVIRONMENTAL HEALTWWT MENT <br /> ,jERVIC QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::: <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> (-':Ar1Jp Ce WF J OCAlip <br /> FACILnYNAME vl_-(yl Ae ne 6a T <br /> SITE ADD <br /> 'R7ESS � t f2OLY (� 11f� <br /> /O� Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> h Street Number Street Name <br /> CITY STATE ZIP <br /> e <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> G-rM —�2&7— '/�253 PR - (0-700c,?C{�;Z <br /> PHONE#2 ExT. BOS DISTRICT LOCATI N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME _.-..._ _. PHONE# ExT. <br /> HOME Or MAILING ADDRESS ____----..-._...---_.....__..-----.__._...__._.___ - FAX# <br /> CITY STATE 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 FEDDEERAL,rlaws. <br /> APPLICANT'S SIGNATL , 'J XI� %� N� '%` 1�,� DATE: /,--?Z9 1 7 <br /> PROPERTY/BUSINESS OWNEM \� r OPERATOR/MANAGER 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> elnU4 A�WAM�v I-Is IT <br /> COMMENTS: <br /> RECEIVED <br /> DEC 19 2007 <br /> SAN JOAQUIN COUNT`( <br /> ENVIRONMENTALENT <br /> ACCEPTED BY: r J EMPLOYEE#: ATE: <br /> ASSIGNED TO: G Q7 EMPLOYEE#: �rDATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C:- P 1 E: v 2,- <br /> Fee <br /> iFee Amount: ` b °u Amount Paid Payment Date `Z , 01 <br /> Payment Type t� Invoice# Check# �'?(� Received By: . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />