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SAN JqRONMENTAL HEALT) 'SPARTMENT <br /> IL <br /> —C ��7T <br /> CE REQUEST <br /> Type of Business or Properly CCi$ FACILITY ID# SERVIC EQUEST# <br /> OWNER/OPERATOR t t.i 7 `.`_RV!C:G <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Wdk, <br /> r,n„ „w( <br /> SITEADDRESS <br /> �1�5 aJ 4ty5" <br /> , �5 Fwl r M <br /> Street Number Direction t Name C ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#I ExT• APN# LAND USE APPLICATION# <br /> (201) 331-7(p(o-7 ' ''j <br /> PHONE#2 ExT• BOS DISTRICT/ LOCATION CODE <br /> ( ) '7 11 12— <br /> CONTRACTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ©)Y t ULA <br /> L -Ma- CHECK If BILLING ADDRESS <br /> BUSINESS NAME vLa le.W `df/r V t !� Eur. <br /> HOME Or MAILINc%ADDR SF <br /> 'G07 - .Ire Gt ( 6) <br /> CITY G: „ STATE CA- ZIP 95&-7/ <br /> 5 _-7/ <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 ENvIRoNNIENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 laws. <br /> APPLICANT'S SIGNATU : , ,0� �_ DATE: ® -' eo <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 4 /1 G T <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 andL"he same time it is <br /> provided to me or my representative. �G <br /> TYPE OF SERVICE REQUESTED: L,4- ( 7-;e_,5 <br /> COMMENTS: oi+` C1 COVN� <br /> sP��O oN <br /> N���H MEPP <br /> ACCEPTED BY: F+L L; �/ EMPLOYEE#: `.�2/ DATE: 1 / <br /> ASSIGNED TO: Cc a EMPLOYEE#: /4,2 --)— DATE: (C1/4J a <br /> Data Service Completed (if already completed): SERVICE CODE: C P 1 E:-� .-2 e <br /> Fee Amountl cZ Amount Paid �3�S; Payment Date ® Ip <br /> Payment Type ✓ Invoice# Check# 3 Received By: <br />