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Nov 06 14 04:14p i1 IV Contactors 1209 6342 <br />SAN JOA U <br />Q IN COUNTY ENVIRONMENTAL HEALTH .d PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-- <br />FACILITY ID # <br />� <br />L Code <br />_street Name <br />zip <br />OWNER I OPERATOR <br />ICT _ <br />�� <br />LOCATION CODE <br />1 `� <br />PIE: 23 <br />EMPLOYEE M <br />ASSIGNED To: 1Nlr <br />FAGILRY NAmE <br />EMPLOYEE M <br />Date Service Completed (ifatrea y completed): <br />SITE ADDRESS <br />gee <br />tenet Number <br />�e� <br />DErectlnn <br />Fee Amount: ft ; �`% <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Name <br />Payment Type i <br />Invoice # <br />51reet Hamper <br />CITY <br />STATE' <br />PHONE #1 <br />ExT. <br />APN <br />LAND U'�: <br />rrn.Nr nF <br />{ <br />REQUESTOR , <br />BUSINESS NAME adf <br />HomE or MAILING ADDRESS <br />CITY \i_,. s, 1 <br />BOS DI,i <br />P.1 <br />SERVICE REQUEST # <br />eg- co 70c9 44 <br />CHECK it BILLINq ADDRESS® <br />-- <br />��Qyhf <br />C t <br />� <br />L Code <br />_street Name <br />zip <br />1PPLICATION # <br />ICT _ <br />�� <br />LOCATION CODE <br />1 `� <br />CONTRACTOR t SERVICE REQULSI OR <br />i <br />I' <br />l <br />r? n STATE <br />AILLMG A KNOWLEDGE NT: I, the undersigned property or business owner, n Ierator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTNENT 1: o rly charges associated with this project <br />or activity will be billed to we 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 d ne in accordance with all SAN JoAQuiN <br />COUNTY Ordinance Codes, Standards, STATE and FEDWL laws- 1 <br />APPLICANT'S SIGNATURE: �'� D 'rF: <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED Air Ei r 1 <br />If.4PPLICANT is not the BILLING P�lR7y proof Of authorization to sign is repel h d Titre <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner sir Iperator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical tial . and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENviRoNmENTAL HEALTH DzPARTMENT as soon a: it is available and at the same time it is <br />provided to me or my representative. {� <br />TYPE OF SE gEQUESTED: <br />L <br />7 2A <br />�'EN�R liM�A1. <br />HE,n4 OEPAR FJ�r <br />1 3 <br />ACCEPTED 13Y: i, -,r t, <br />PIE: 23 <br />EMPLOYEE M <br />ASSIGNED To: 1Nlr <br />O% <br />EMPLOYEE M <br />Date Service Completed (ifatrea y completed): <br />5ExVICECODI <br />Fee Amount: ft ; �`% <br />Amount Paid:" 3,70, 0-6 <br />p; <br />Payment Type i <br />Invoice # <br />�r <br />L <br />NOV 4 G 2014 <br />DATE: t t <br />DATE: <br />1 3 <br />PIE: 23 <br />nent Date <br />11 7/ <br />O% <br />Received By: <br />EHD 4M2-025 SR FORM (Golden Rod) <br />REVISED 111/17120,05 <br />