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I,6.. <br />� <br />rCFJ'VED <br />SAN JOAQUIN CBb�4NV�®i7 <br />IRONMENTAL HEALTH DEPARTMENT <br />NV <br />-REQUEST <br />Type usiness or Property HEALTH Da <br />FACILITY ID # <br />9 <br />SERVICE REQUEST # <br />DATE: <br />ASSIGNED TO:&W-14 <br />EMPLOYEE #: <br />OWNER / OPERATOR <br />SA%K r (I r; <br />CHECK If BILLING ADDRESS <br />oY <br />` i 1^ <br />1 <br />FACILITY NAME <%&we*eLbkw <br />Fee Amount: <br />E DD S 800, <br />Amount Paid <br />Payment Date a l <br />het N r <br />city <br />Zip Code <br />E Or MAILING ADDRESS (If Different from Site Address) <br />3 0,utid d V �� Street Number <br />Street Name <br />CITY/, n U L' <br />/� I <br />STATE ZIP <br />PHONE #1 E •( APN # <br />LAND USE APPLICATION # <br />PHONE #Z EXT• `.;i <br />OS DISTRICT LOCATION CODE <br />a <br />,t <br />REQUESTOR ,I <br />BUSINESS NAME <br />CONTR)W.-f" kSUR <br />PoKi VFK r'y'e <br />`� .v' kM; <br />HOME or MAILING ADDRESS ^ '\Vr% .,C"tI I FAX # <br />CHECK if BILLING ADDRESS <br />Ext. <br />CITY V�L/�. � (S V-1 b ��� ""N 11_'STATE , k ZIP <br />BILLING ACKNOWLEDGEMENT:W <br />ned grope or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or projeONMENTAL H LTH DEPARTMENT hourly Charges associated with this project or <br />activity will be billed tome or my busin on this form. <br />also certify that I have prep ed thisthat thew to be rformed will be done in accordance with all SAN JoAouiN <br />COUNTY Ordinance Codes, St dard AL la <br />APPLICANT'S SIGNATUR DATE; L- --C <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ 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 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 time It Is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: V �JN <br />COMMENTS: ro t /�� OA) L7wa 0�� <br />ACCEPTED BY: <br />9 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO:&W-14 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: v <br />Fee Amount: <br />2 <br />Amount Paid <br />Payment Date a l <br />Payment Type <br />Invoice # <br />Check # <br />Received By: ; - <br />J <br />EHD 48-02-025 C'/ k -S SR FORM (Golden Rod) <br />07/17/08 -4 <br />