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SAN JOA, N COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cis S om �9�q 6xCV6 Asez-1 <br /> OWNER/OPERATOR ElCHECK if BILLING ADDRESS LJ <br /> FACLRYIdAIv1E <br /> SITE ADDRESS SSD �, �alpt[:D ack Tr-GG� <br /> Street Nnntbe Dhectlou Street Name CI Zip(..011e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sneer Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Rz� l 5��'-7�i►n 2�-Ig-alp- I� <br /> PHONE#2 ExT. BC1S DISTRICT LOCATION CODE <br /> CONTR-At-'TOR / SERVICE REQLTESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> •'1 C✓ ( ) <br /> HOME or MAILING ADDRESS / / FAX# <br /> CITY STATE ZIPCZA <br /> C�J <br /> BILLING ACKNOWLEDGEME : I, the undersigned property or business owner. operator or authorized agent of same. <br /> acknowledge that all site andior project specific ENVIRONMENTAL HEALTH DEPARTMENT hOUrly charges associated with this project or <br /> acti\ity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be clone in accordance with all SAN JO.AQUIN <br /> COUNTY Ord-nance Codes,Standards. FATE and FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT CI <br /> IfApoUCAN7:s not the&f LING P.APTY. 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 environmentalisite assessment information <br /> to the SAN JOAQU N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Sam time it is provided to me or <br /> my represents <br /> TYPE OF. D; (�S% I�201�f9L <br /> CONWENTS: L W3 NOV <br /> 26 <br /> 20 <br /> ''VVUU "N111110 13 <br /> SAN JQAQUIN COUNTY PERMN4fERV11' <br /> HEALTH DEPARTMENT <br /> CFS <br /> ACCEPTED BY: --j l EMPLOYEE# �% DATE: l• -Z46, f <br /> ASSIGNED TO: -00!,v EMPLOYEE# "1(/ 4 DATE: � � ` r <br /> Date Service Completed (if already completed): SERVICE CODE: •ZI P/? /13' <br /> Fee Amount: r D Amount Paid 5-� 212 Payment Date � 3 V <br /> Payment Type v Invoice# Check# j 3(� Received By: <br /> EHD 48-02-025 `2 SR FORM (Golden Rod) <br />