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Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> OWNER I PERATO'yea /-o)" do r Crrecx if BILLING ADDRESS❑ <br /> FACILITY NAME f N n 4 .Al <br /> SITE ADDRESS LJ ` i g 5 Z t f d <br /> S Street Number Dire n �"/JStre N L� �CI Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Str et me <br /> CITY r STATE zip <br /> PHONE#') EXT- APN# LAND USE APPLICATION# <br /> (7_o9) 3 3 y - .S 8 g "'I <br /> PHONE R Exr• SOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR .. CHECK ff BILLING ADDRESS <br /> AJ / 44 Nc7 <br /> BUSINESS DAMEPHONE# <br /> T <br /> P0—aL 7�- (yl& q <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �' G I r ✓ 7 y 56 STATE A ZIP <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 /> 1 also certify that I have prepared this lication an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Staudardr AT d F laws. <br /> APPLICANT'S SIGNATURE- DATE: i 2 <br /> PROPERTY I BUSINESS OWNER❑ PERATOR I 'AGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BzLiNG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the sarrAtime it is <br /> provided to me or my representative. +q Y <br /> TYPE OF SERVICE REQUESTED: p M M f ;q L S PA �cMv b r L CE NT <br /> COMMEM: NOV o 5 F� <br /> Say 2 0 <br /> R Tn' Nr <br /> ACCEPTED BY: EMPLOYEE#: 043 DATE: <br /> ASSIGNED TO: „�_- EMPLOYEE#: : z 3 DATE: <br /> Date Service Com eted (if already completed): SERVICE CODE: <br /> Fee Amount: 3 Amount Pai ,30 �� Payment Date jr �� <br /> Payment Type �s Invoice# Check# /L, 7 Ls Received By: <br /> EHD 48-02-025 REVISED 1 /17/2003 C�h � `Lti�_� � � i , i � � � �� i ,` SR FORM(Golden Rod) <br />