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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 and DERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />DATE: <br /> /7 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ <br />FACILITY ID # SERVICE REQUEST # <br />5 KCG-F---i -Ili II <br />OWNER! OPERATOR <br />CHECK if (11c,/14 i (V \ “ /1/ / A C <br />BILLING ADDRESS <br />FACILITY NAME <br /> A 4,1,) .-•.,z-•6,c,...i--6,(7 95g/ 7 Street Name City Zip Code <br />SITE ADDRESS <br />3 Street Number Direction <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />MI 9-10°1 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />0 0 k j <br />LOCATION CODE <br />00 [ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r z5-Q-0 5a HECK . If BILLING ADDRESS <br />BUSINESS AME Pk/ PHONE # <br />( W ) 77 5 -?q'i4 <br /> .4,Err. <br />HomE or MAIAaADDRESs <br />R 45 Eit'n HOX 6--fg. i P <br />FAX # <br />( ) <br />CITY K9 cv77. (.7 ZIP 9573Z jr:5 <br />BILLING A KNOWLEDGEMENT: 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 />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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: R C'eli‘ l'i\I T <br />AUG 1 7 <br />' 1 20b 2 <br />—loon, , -Nvi R0A, • colit,,„, <br />"E41-7711);114ev7AL - I <br />i ACCEPTED BY: ‘- L L 't . 429) EMPLOYEE #: ot.q..0 -7DATE: <br />41-irt .r_ <br />1 (11 ob <br />ASSIGNED TO: Ck_ li `lik.32--vi.,t.-, EMPLOYEE #: 0 q & 7 DATE: j ifOk <br />Date Service Completed (if already completed): SERVICE CODE: c----2_ -- <br />T.- <br />Fee Amount: <br />3 <br />0 . 0....0 Amount Paid "6 c:8-b . (so Payment Date <br />ili7 q (cb <br />Payment Type L------- Invoice # Check # t_k ck \,..1\ 2) <br />• <br />Receitied BY. <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003