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rformed will be done in accordance with all SAN JOAQUIN <br />DATE: <br />I also certify that I have prepared this application . id that th <br />COUNTY Ordinance Codes, Standards, STATE d F DERA <br />APPLICANT'S SIGNATURE: <br />ork to be <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY <br />fle0000 CIP-14 <br />ID # SERVICE REQUEST # <br />cPaSSq6s <br />OWNER! OPERATOR <br />M az e ( pJt ckPJofte,J1 \-- Comp GIVt <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />10 )c 61L Af (04eA h <br />SITE ADDRESS <br />L I I Street Number 1 Direction tEk 61 Por 1 Street Name <br />A. V6 A4 o/ k c ok 0 e <br />City <br />(/-6 337 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />(21) )1 70 ''' '-, ()b. .5 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />(iv S 1 4V0 )1) v)1:( vljJ 2- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME (ID )5 1-,,„\e_ ottid Po 0 1 ei as i_ef) i?y P(Hert ) 7i3 _ Err. 47046 <br />HOME or MAILING ADDRES6_ FAX # <br />CITY ,5 to co_ ov) STATE C A ZIP <br />BILLING ACKNOWLEDGEMENT: 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 />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />PAYRAFNT <br /> <br />RECEIVED <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />OF above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site FIRIsitept 2021 <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. SAN JOAQUIN COUNTY NTAL <br />TMENT <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />M3100501 <br />If APPLICANT iS not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />HE-kiii- `i I iSiWA TYPE OF SERVICE REQUESTED: c.eAvv332A ‘1,1 5 i` 113 ,54.7-tenY6 Ifl, POO 1 <br />COMMENTS: <br />i io ,, ,h, <br />i Q7-15 1°•Sfet e_,I.tbiAiTi sLtitmiCmj lopoi a, Lscki, ,r ci„ 64 <br />' tn 5IiAli U() to code, illc af-emtA uoucit. tvicArKt r S <br />j 17,,,SI-ct\t, ‘IQ to Cu d(, 1 -VAAJ roa I <br />ACCEPTED BY: L 0 tAros „...c . EMPLOYEE #: gigo DATE: V--/2/ /0/ <br />ASSIGNED TO: ttA oo e_ __F- . EMPLOYEE #: I -46 DATE: q12,1 124 <br />Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br />Fee Amount: A .0/_/, .O0 Amount Paid <br />3 0 V — <br />Payment Date 17/-2 1 / <br />Payment Type (Az , Invoice # Check # 2A0 / 0 Received By: