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PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST EXn IRE <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE # ,e��0 <br />HOME Or MAILING ADDRESS f/ o �, V � <br />I �� <br />FAX # <br />CITY a otd / 4/W <br />OWNER / OPERATOR 1" V / /ti y <br />wT <br />EMPLOYEE #: / J _) <br />L/v <br />CHECK If BILLING ADDRESS E] <br />FACILITY NAME <br />EMPLOYEE #: <br />SITE ADDRESS 3 / <br />Date Service Completed (if already completed): <br />/V(V �S•tre%t <br />Fee Amount:57 <br />/ <br />! <br />Street Number <br />Direction <br />Name <br />Recei d By: <br />Cit <br />Zip Code <br />HOME Or MAILING ADDRESS If Different fro Si a ress)Iert- <br />/l <br />`� `, / li/r. <br />Street Number <br />et Name <br />CITY J Foe k, c( e-0 <br />J�, —� <br />STATE /� ZIP A ,/ A �l <br />` Or j <br />PHONE #1 /� / L/q� — jT / // , <br />APN # <br />1 �J 7` 1 � _1 <br />LAND USE APPLICATION # <br />PHONE ill EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /,���� W/ -t / , <br />i�r ���(� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME /L%iJ A /�/ . / [J /7�L <br />• <br />PHONE # ,e��0 <br />HOME Or MAILING ADDRESS f/ o �, V � <br />I �� <br />FAX # <br />CITY a otd / 4/W <br />STATE e t ZIP q b <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />nowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or <br />�tivity will be billed to me or my business identified on the form. <br />/ >,"J <br />MIso certify that I have prepared this a pli ation and thgt'the ork to be performed will be done in accordance with all SAN JOAQIMIYrj <br />LINTY Ordinance Codes, Standards, T E a,F DER law <br />4PPLICANT'S SIGNATURE: DATE: <br />OdiROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT!� PA11 <br />11111IM;® <br />' If APPLICANT is not the BILLING PARTY, proof of authorization to sign is require Title 1' IFVIEl <br />RF^^�� �iv <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the abo�C� <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment intim Ion <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS pro V'ded �0� <br />t01Tle � <br />my representative. /% �_ ✓Oe. . <br />TYPE OF SERVICE REQUESTED: C�LA�''T <br />iRONM <br />COMMENTS: <br />MUM C1c�✓�z �1(� j'10 l e C <br />ACCEPTED BY: <br />EMPLOYEE #: / J _) <br />L/v <br />DATE:s % 7® J <br />t3 L <br />ASSIGNED TO: ' <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />$ERVICE CODE: V P I E: <br />Fee Amount:57 <br />Amount Pai �� <br />1 <br />Payment Date S <br />Payment Type <br />Invoice # <br />Check # <br />Recei d By: <br />EHD 48-02-025 <br />07/17/08 <br />PERMIT <br />EXPIRED <br />SR FORM (Golden Rod) <br />C <br />Nr 4 <br />TMFNr <br />-a;/0 <br />