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I also certify that I have prepared this <br />COUNTY Ordinance Codes, Standar <br />APPLICANT'S SIGNATURE: <br />p • lication and th the work to be performed will be done in accordance with all SAN JOAQUIN <br />ATE and F laws. <br />DATE: <br />OTHER AUTHORIZED AGENT <br />E:v/p1-- 014243. <br />PROPERTY / BUSINESS OWNER': OPERATOR / ANAGER <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />5/0.EAtrAz— <br />FACILITY ID # SERVICE REQUEST # <br />*CO sb43.17 <br />OWNER/OPERATOR <br />MR • PA v r D PI AlA I 414- <br />CHECK if <br />FE , <br />BILLING ADDRESS LA <br />FACILITY NAME <br />SITE ADDRESS ege fig <br />Street Number <br />tA/ <br />Direction <br />.3 TREer teivr-oW <br />City <br />q_.5--g <br />Zip Code <br />f7/,',ç <br />Street Name <br />HOME Or MAILING ADDRESS (If Different from Site Address) 5-764 <br />Street Number <br />VJ.EE S r x/A/p0,41' <br />Street Name <br />CITY .7--. _ <br />11-1-Ort TOW <br />STATE ZIP <br />CA 1S-6 e4 <br />PHONE #1 EXT. <br />C91°I ) 40 0 — eas-s <br />APN # <br />40—.200 --,2o <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />) <br />0 0 I — <br />( <br />BOS DISTRICT L LOCATION CODE <br />CI 9 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR D on) G)-f5Nk/ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />-ESN <br /> <br /> <br />v <br />C ChM S VL r/A/(7 <br />PHONE # <br />122-0p <br />/ _ , EXT. <br />HOME or MAILING ADDRESS <br />60V 37/4 <br />FAX # <br />( ) <br />CITY <1 R LOCK STATEar <br />ZIP 4.90 0 / <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 />If APPLICANT is not the BILLING PARTY, proof of aut orization 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: Apoi p /7E-gc 0 LA ri 0/447j 7---/ A 77 DA/ ig po R7-- PA tfa , <br />COMMENTS: pi 6 in c h t 6 k _ L, fi, . ,-/ v..) ei 5 i t _ E Pegferrni) <br />iree r des 1,5h 4frpt) <br />114,1474( g@Phi <br />ACCEPTED BY: EMPLOYEE #: <br />lifgotir <br />DATE: <br />ASSIGNED TO: i j A EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c- 3 P/ E: 11,2 0 ; <br />Fee Amount: .# 30 ,-i Amount Paid 30-[.— Payment Date 7 f- 22( 2_2 <br />Payment Type 0./VLLCA2) Invoice # Check # 48(..0 Ct Received By: ah-171 <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003