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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ifto, SERVIG"-rrr'QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADORESSO <br /> FAciutY NAME <br /> SITE ADDRESS <br /> Street Number I OlrycWn AStreet Name ON Zip Code <br /> HOME <br /> ,IorMAILING ADDRESS (If Different from Site dress) <br /> LA3 3 1 /A` K I /U Street Number Street Name <br /> CITY- STATE ZIP <br /> t wE , Ca . t -330 <br /> PHONE#1T• APN# LAND USE APPLICATION# _ <br /> 1M ) /Li ail — ZdO — (G - O 37 v� <br /> PHONE#2T• BOS DISTRICT LOCATION COpFG� S <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Fbar' <br /> HOME or MAILING ADDRESS FAX# <br /> C h A Iv k "V I ( ) <br /> CITY M A C STATE ZIP <br /> /', 5336 <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 FED RAL laws. <br /> APPLICANT'S SIGNATURE: �c¢_ DATE: 2 /o Leg 5- <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICANT 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 <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. PAYMENT pAVNAENT <br /> TYPE OF SERVICE REQUESTED: 1-N <br /> CORMENT§: �,ltc7L5 ub SJ(� �� L��"D, I`' /�yrFEB 17 Z005 MAY 1 3 Z 05 <br /> rf 1/Y1_/Ml I¢IJV IV7 • . :�¢� Q _;S[tEJOAQUIN <br /> ENVIRONMENTAL <br /> COUNTY <br /> "I �"• 1 `,�V`P JA /rwuwe ENVIRONMENTAL SA ENV JOAQUIN <br /> FAL <br /> J 11 kD COUNTY <br /> �� `1 /� TH DEPARTMENTHEALTH DEPAR <br /> Y'0 <br /> ACCEPTED B _ / EMPLOYEE#: DATE: I� <br /> ASSIGNED TO �����/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): ply-- �r SERVICE CODE: J E: <br /> Fee Amount: Amount Paid r 5`� Payment Date 7;' <br /> Payment Type Invoice# Check# �sj� 9� Received By: <br /> 048-02-025 F"`=` 4J L �- ��� r�n) <br /> �� ���� rY'L� S1(oj10� SR FORM(Golden Rod) <br /> _VISED 11/17/2003 <br />