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---"A A L" IAL IIVALI-H V FAKIIVIEPNT <br />j <br />in I ,SFRVTCF RF01'fl ..QT It� 1--n- <br />Type of Business or Property <br />FACILITY1D <br />SERVICE REQUEST # <br />COMMENTS: t� <br />115 �5r��. <br />OWNER / PERATOR <br />CHECK if BILLING ADDRESS D <br />SAN JO RCNMENT EN <br />FACILITY NAME <br />NTH DEPARTM <br />ACCEPTED BY:7 S <br />EMPLOYEE #: Lt out5- <br />SITE ADDRESS <br />13 01 l� <br />cn <br />Street Number Direction <br />Street Name <br />Ciie <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I E: <br />Fee Amount: _75, . av Amount Paid <br />CITY <br />Street Number <br />Street Name <br />Check # ` 3 <br />Received By: �_ <br />STATE Zip <br />PHONE #1APN <br />( ) <br /># <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />{ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <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, Standar�andL laAPPLICANT'S SIGNATUF—F:_ _ 1 <br />DATE: <br />PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER ❑. AUTAORIZED AGENT El <br />1f APPLICANT is not theBILLiNGP.1RTY Proof of authorization to sign is required <br />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. <br />TYPE OF SERVICE REQUESTED: <br />�f <br />PAYSD <br />COMMENTS: t� <br />SAN JO RCNMENT EN <br />NTH DEPARTM <br />ACCEPTED BY:7 S <br />EMPLOYEE #: Lt out5- <br />DATE: .1 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />I E: <br />Fee Amount: _75, . av Amount Paid <br />L <br />Payment Date <br />3� <br />-7 , 2 <br />Payment Type L,� Invoice # <br />Check # ` 3 <br />Received By: �_ <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Sf� FQE�'N7,(�old"n Rod)''' <br />