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I also certify that I have prepared this a <br />COUNTY Ordinance Codes, Standards <br />ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />E and F AAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / Bt SINESS Ow NERD OPERA TOR / MANAGER 0 <br />DATE: 3//b /oZe7.2/ <br />OMER AUTHORIZED AGENT cr" <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ZE 1 PNII-14 i- <br />FACILITY ID # SERVICE REQUEST # <br />92 0 V <br />OWNER / OPERATOR <br />CHECK if <br />NIZ- MP/natio ,4-5Arzv-looif (rm? /4-342) <br />BILLING ADDRESSED" <br />FACIUTY NAME <br />SITE ADDRESS / / / 6, 0 <br />Street Number Number Direction <br />54 /4 .fo 5 E gs A b <br />Street Name <br />TIZA-Cy <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) ,--7g3 <br />Street Number <br />0 t ( .1._//./ a Lvo. <br />Street Name <br />Crry STATE ZIP <br />CA <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( go2C ) <br /> BOS DISTRICT ----- LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME NAME <br />ei'l leY Ce A/c u Lr-likur <br />PHONE # , <br />(a241) 4 az- -16--01 <br />Err. <br />HOME or MAILING ADDRESS <br />po . gox 7 4/-4- <br />FAX # <br />( ) <br />CITY --T- <br />U" <br />STATE A A <br />L-tt <br />ZIP 9 530/ <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 <br />or activity will be billed to me or my business as identified on this form. <br />PPLICANT is not the BILLING PARTY, proof oJw thorizaiion 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: 5 5 A/L. R _ v/ .0 IA/ R. kanr&lif NT <br />COMMENTS: <br />_,..,/vel) <br />, ., , R l g., <br />SAN , v 4u21 - 1„o,,,,,„7 couNry --11-TH oE,revrAL Afm,,E.,vr <br />ACCEPTED BY: Z-Z-- ..,----- EMPLOYEE DATE: DATE: <br />ASSIGNED TO: A) 4 EMPLOYEE #: DATE: OCii 1 <br />Date Service Completed (if already completed): SERVICE CODE: sa3 PIE: <br />Fee Amount: .-,C_.)-7 Amount Paid t90t3,f— Payment Date <br />Payment Type avaki Invoice # Check # /* (sq. a Received By: a ICl/ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003