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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE BEQUEST <br /> Type of Business or Property FACILITY ID# SERVICE-1REQUESTq# <br /> fz. t "( 4- <br /> OWNER I OPERATOR <br /> �Aoli CHECKif BILLING ADDRESS <br /> FACII-n NAME <br /> SITE ADDRESSSTS <br /> Street Number Direction / Sireel Name CiN Zio COAD <br /> HOME or MAILING ADDRESS <br /> 1^(If Different 11frloIn Site Address) <br /> kw-? �IR«1�t41� r• 'A- Street Number street Name <br /> ,r CITY t STATE ZIP <br /> S ock�on <br /> 5 O <br /> l PHONE#t EZT• APN# LAND USE APPLICATION# <br /> (2cn X74- a 0 4 <br /> l (' q ( 332 <br /> 9 ExT BOS DISTRICT 0 t LOCATIO IV ODE <br /> I V v <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDP,ESS <br /> BUSINESS NAME PHONE# Ex . <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 an FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: D174A4ZDAv : — g —/ S' <br /> PROPERTY/BUSINESS OWNER 13 OPERATORIMANA. R ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPtICANT is not the BILLING PARTY proof of authorization to sign is required Tiife <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same timeit is provided to me or <br /> my representative. P <br /> rOFSERVICEUESTED: 1� sqAN 08 2015 <br /> 1fN�AQU11V C <br /> HfACTFI pO of���NTy <br /> NT' <br /> ACCEPTED BY: e EMPLOYEEM DATE: L d t <br /> ASSIGNED TO: LA- h EMPLOYEE#: DATE: l <br /> Date ServicaCompleted (if already completed): SERVICE CODE: �A � PIE: t�o' <br /> Fee Amount: 1 30 Amount Paid I 'JJ. D Payment Date ( 911s <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48�02-025 <br /> 07/17/08 SR FORM,(GDIc!an Rod) <br />