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APPLICANT'S SIGNATURE <br />PROPERTY / BUSINESS ON <br />DATE; _ <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />/ S3 6r2- <br />SERVICE REQUEST it. . <br />f,-0069 ,00 51 .. <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME in - <br />vme.. v ee2: ,1 trMin, b 7-7 Z-GP!/51 <br />SITE ADDRESS <br />Street Number Direction / 1 4-% 4", i /(4=.17/(treet‘Tre4 Spix ie,:xed -7 city 5-,7,a7e, -7 . code/ <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br /> <br />Street Name - - - _ - <br />CITY STATE ZIP <br />.. .. .. <br />PHONE #1 Ex-r. APN # LAND USE APPLICATION # . <br />PHONE #2 Ex-r. <br />( ) <br />BOS DISTRICT .2._ LOCATION CODE <br />l <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOD I <br />4v/V Mr/ 2, <br />CHECK if BILLING ADORES <br />BUSINESS NAMEp <br />4ragiel/7 fir2 0 Itil <br />PHONE # <br />kV 't/ ) 7‘/ 2' ?-107 -S.) <br />HOME X MAILING ADDRMS <br />$1-ii" -• A' ik ,? <br />FAX # <br />sf ),3,?- 6 ?-2 2 <br />c'TY A zit- ,014,,a r STATE"' ZIP vi--, 2 )---g <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 done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE.a EDERAL laws. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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. p0.04._ ,c,„44( .-te 04 cc cy-bEz(L_ _ <br />i f PAY IVI r.1 a i <br />TYPE OF SERVICE REQUESTED: 1/6,B 1-4/5 /010 Air RFCEIVED <br />COMMENTS: <br />00 jot, <br /> <br />MAY 2 0 2010 <br />......., .... „ 0. <br />' SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: irrat EMPLOYEE #: 67674 3 DATE: GA* / 0 <br />ASSIGNED TO: irpja4A/ret EMPLOYEE #: 642/ 3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Ca" P I E: 3620.2, <br />Fee Amount: .,....3 . (.7.0 Amount Paid •Z D — Payment Date 512,C,, jib <br />Payment Type LZ-- Invoice # Check # .5 i l. \ Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003