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I also certify that I have prepared this applicati <br />COUNTY Ordinance Codes, Standards, STAT <br />APPLICANT'S SIGNATURE: <br />th <br />F ERA <br />, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />R7717 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS 0 0 <br />Street Number <br />Pri. in 0 iyiii7 <br />I a9A,e pi <br />Direction 1 Street Name <br />7-fae/ <br />City <br />r5'3,‘ <br />Zip Code <br />HOME or MAILING ADDRESS f Different from Si e Address) <br />'act o a 3/e'e- C't Street Number Street Name <br />CITx.-----, STATE ZIP PA /9 I if <br />Ira (' r - n'.3 -?‘ PHONE #1 EXT. APN # LAND USE APPLICATION # Ell <br />PHONE #2 EXT. BOS DISTRICT Lotikm Cojpg - <br />1- 41 op'etir . —PARrii CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR-.:0--C- f00 9 £11 HECK if <br />a k (7 07,7/17 6 ei- <br />- Jr ''' <br />BILLING ABORESS M <br />BUSINESS NAME 6-07 ___77--/e pi p/a,.5.74.0/2 PH.ONE/#1 ..?,....._....,_ ExT. <br />7 0 657 <br />HOME LA i HOME or MAKIN.q ADDRESS <br />J i iti-2e ) A ve <br />FAX # <br />( ) <br />Crry <br />C )-7 /C kfo/' r41 ts--20 5 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 or <br />activity will be billed to me or my business as identified on this form. <br />0.3 <br />t'vrY <br />t the work to be performed will be done in accordance with all SAN JOAQUIN <br />laws. <br />DATE: 9- 5-// <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER0 OTHER AUTHORIZED AGENT 14- <br />If APPLICANT 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: F001 gele<As tri Re.4'n.044^ F kto 1-1.(c - <br />COMMENTS: <br />aii <br />/ /2/157/ed - ,p?, tA)1 0 1,46 --1(rw iedi 1-0 044,1. <br />e <br />....., <br />ACCEPTED BY: lir D: EMPLOYEE #: DATE: 5-- (tc,,,, <br />ASSIGNED TO: VI Oia, 1 Pectir, EMPLOYEE #: DATE: g1911(,, <br />Date Service Completed (if already 3 ornpleted): SERVICE CODE: c._;-'2•3 P/ E: <br />Fee Amount: 4 24D-op Amount Pa' 2_60. OD Payment Date <br />Payment Type Invoice # Check # i 02:y Received By: a <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08