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PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PERMIT <br />EXPIPF-n SERVICE REQUEST EXPIREC <br />Type of Business or Property <br />FACILITY ID # <br />SERVJFE <br />REQUEST # <br />FAX# <br />) <br />CITY PERMIT K STATE ZIP q5 ZZ 0 <br />SAT <br />EMPLOYEE #: ) <br />OWNER /OPER��TOR <br />V <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SERVICE CODE: <br />PIE: <br />SITE ADDRESS <br />LU12 r <br />Amount Paid <br />�� C <br />Payment Date <br />Payment Type CL_ <br />I Invoice # <br />"0 Street Number <br />Direction <br />I <br />1 Street Name <br />HOME or MAILING ADDRESS (If Different from Site Addr s) <br />PA <br />�'1 <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />ILILZ '11W <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />ii 11 <br />PHONE #2 EXT. <br />�6cf) -)y7— yO2C <br />BOS DISTRICT <br />LOCA �pNM <br />EPq <br />CONTRACTOR/ SERVICE REQUESTOR t <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME � M \ <br />_� L4 O 1 EXT. <br />PHON f I � <br />HOME or MAILING ADDRESS <br />2,I,Qti Z 4vv Orl( <br />FAX# <br />) <br />CITY PERMIT K STATE ZIP q5 ZZ 0 <br />Weivr <br />E® <br />2019 <br />NTUN7y <br />tTMENT <br />BILLING ACKNOWLEDGEMENT: I, the undekgtteld ;VbIt;W 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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ������ l DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR I MANAGER El OTHER AUTHORIZED AGENT El <br />If APPLICANT IIIIS 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 t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: C Vv <br />COMMENTS: I f 51 rr/ Yom// GQ�/ � � C�-CJ��'v _ 7- <br />- <br />CAk, (2,A) 1s3 - 76 q 7 7-0 scir�rx c,� �� �I�.,' <br />pwti t - A �e ; � Z <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: ) <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type CL_ <br />I Invoice # <br />Check # 527 <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />0717/08 PERMIT PERMIT <br />EXPIRED EXPIRED <br />