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SAN JOAQU V COUNTY ENVIRONMENTAL HEA 'I DEPARTMENT <br />SEAVICt REQUEST <br />Type of Business or Property <br />L A%4JbF1L. <br />FACILITY ID # <br />2O <br />SERVICE REQUEST # <br />G <br />OWNER / OPERATOR <br />_ > <br />uS�� 2�rr <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Li pEPAR <br />ACCEPTED BY: 0- Q ��� <br />EMPLOYEE#: sR -7'?> <br />SITE ADDRESS <br />Street Nu✓tuber <br />Direction <br />Street Name <br />DATE: <br />Ci <br />1 Zi/Code <br />HOME Or MAILING ADDRESS (if Different from i e <br />s) <br />Street Number <br />Fee Amount: �Gl, V® <br />Street Name <br />Payment e <br />CITY <br />Payment Type ✓ <br />STATE zip <br />Check # rC S� <br />PHONE #t XT <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />JLOCATIONN <br />( ) <br />BOS DISTRICT <br />CODE <br />6 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST. -CHECK if BILLING ►. <br />BUSINESS NAMEPHONE# <br />;,r..'t�. o ct Paes <br />HOME or MAILING ADDRN60 VkAJ&`1 VISTA ESS <br />MIV6 <br />« <br />i <br />r <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 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 doK in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, SlAlzand FEDERAL laws. <br />C- <br />APPLICANT'S SIGNATURE: - DATE; I <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT 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 <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 —5l1-6 L):n ` <br />COMMENTS:!g/3/pS GC r5 fl /rt ✓!'lS zu, Iry <br />2O <br />_ > <br />uS�� 2�rr <br />SP�NOR�NNyEO�M�N~( <br />Li pEPAR <br />ACCEPTED BY: 0- Q ��� <br />EMPLOYEE#: sR -7'?> <br />DATE: i� ac°' <br />ASSIGNED TO: M j <br />EMPLOYEE #:'7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Tv <br />P1 ®® <br />Fee Amount: �Gl, V® <br />Amount Paid *x'79 <br />Payment e <br />p <br />Payment Type ✓ <br />Invoice # <br />Check # rC S� <br />Received By: 2r� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />