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APPLICANT'S SIGNATURE: <br />! PROPERTY / BUSINESS OWNER 61( OPERATOR / MANAGER El OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION 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 />DATE: <br />/wile <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE RE UEST <br />Type of Business or Property <br />'-f.tAtil Wirl' <br />FACILITY ID # SERVICE REQUEST # <br />S'k• 0-1/4) &,s S <br />OWNER ! OPERATOR,7 <br />in i‘ Al.i <br />1 <br />I 1 ) 41 ,2 /1 CHECK if BILLING ADDRESS <br />(") FACILITY NAME <br />01 ft LA Ctli . Z.Arier (1/1.5 el k-tdt <br />SITE)DDRESS <br />/04 Street Number Direction <br />at 1",z6.c 4-ve p <br />Street Name <br />if.2,c.)c Art, . <br />City <br />f52o4 <br />Zip Code <br />HOME or MAILING ADDREOS (If Different from Site Address) <br />3,25 4 ey C <br />Street Number <br />KO( ei 6 r <br />Street Name Orr <br />Q>070(41)4 <br />STATE ZIP rAk 15 2-0 7:1- <br />PHONE #1 <br />V%i21) <br />EXT. APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. II <br />( ) Ii <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME PHONE # Exr. <br />( ) <br />HOME or MArLING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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 />I also certify that I have prepared this application and that the vhork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />7 <br />TYPE OF SERVICE REQUESTED: <br />PAYMENT <br />RECEIVED <br />COMMENTS: JUL 13 wi9 <br />..„.....,..:..,...., <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 7-12-22 <br />ASSIGNED TO: Lydia Baker EMPLOYEE #: 9818 DATE: 7-12-22 <br />Date Service Completed (if already completed): SERVICE CODE: 523 / PIE: 1601 <br />Fee Amount: 468 Amount Paid f (.6 L 2 ---- Payment Date --/i i <br />Payment Type v1,5 A Invoice # gb.eek-# ji41.3(„(,2_1 <" Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Payment confirmation 146/366215 17142,c <br />SR FORM (Golden Rod) <br />c3P. I to D'-1-1--