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Type Business oror Property <br />OWNER f OPERATOR N <br />FAcIurY NAME <br />SITE ADDRESS 40 1 <br />c �• • uv,. . iia r ii�vtvirlty tAL "LA -U-1 VtJ Ali1181EN'l- <br />SERVICE REQUEST <br />SERVICE REQUESTckA o 6 7 <br /># <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />PHONE #t <br />( <br />PHONE #2 <br />I <br />REQUESTOR <br />BUSINESS NAME <br />t <br />NOME or MAILING ADDRESS <br />CITY -•. , . I ` <br />APN # <br />ExT. <br />CHECK if BILLING ADDRESS E] <br />5 <br />STATE ZIP <br />LAND USE APPLICATION # <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />J k:) V-- z <br />if BILLING ADDRESS <br />6" A <br />�,.�` "-� 1 F . <br />- ?-" <br />N) q 61-�0 �)q <br />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 />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 FEDERAL Iaws. <br />APPLICANT'S SIGNATURE: DATE: l o <br />PROPERTY/ BUSINESS OWNER L I OPERATOR/ MANAGAL <br />THER AUTHORIZED AGENT tJ�,-��,+,_ 1� ( s n (A <br />If,3PPLIC4NT is not the BILCINr,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 <br />above site address, .hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />infortmation 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: — P <br />COMMENTS: <br />ACCEPTED <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: C,( C,—c Amount Paid <br />Payment Type V- I Invoice # <br />APR CE/Veo . <br />SANJa <br />elvoAQUJIV C <br />i1Q�r° pMeN111UN�,. <br />EMPLOYEE M „ �� DATE: A � .. . <br />EMPLOYEE #: SATE: <br />w <br />SERVICE CODE: Ct P f E, <br />J L/e <br />34G, — Payment Date L41141' 0 <br />Check# 1 q Received By: Lb <br />EHD 48-02-025 <br />REVISED 99/17/2003 Sf FORiv1(t?o]_cien Rotl) <br />