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SAN JOAQUVOUNTY ENVIRONMENTAL HEAL <br /> 1WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ti)-�uhJC -�-'A C' -T VA 000 0(0-7 Z 164 <br /> OWNER/OPERATOR PILOT _T(7-AIJEL LL6 CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME r / , '�;� /� / � r �� L L 0, <br /> SITE ADDRESS I v l..1/ ��Y` KC._--T_ >t. 1�G�A (� 1Z (�v .?5�4 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site <br /> Address) / ©1,146 )20 A <br /> 5 0� �-04A Y�-o' Street Number Street Name <br /> CITY O l STAT ZIP 3-19 <br /> Oct <br /> PHONE#1 L Exr. APN# LAND USE APPLICATION# <br /> Au <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I Imo'< a'/yam 6 /20 Z� � y� /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME /�(� <Cr / Vv / l l� PHONE# <br /> a a-7 U <br /> HOME Or MAILING ADDRESSJ p' AX <br /> , t,U e AS G^ oq) 4S4`0 5Q o- <br /> CITY anc o o CJ >)o0&A '0C ,�moi( ( <br /> STATE CA ZIP L 3Z 1 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared • application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan ar , =RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: � ,� � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN GER ❑ OTHER AUTHORIZED AGENT 0 jJTRAt5,� <br /> If APPLICANT is not L 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> (_L- PtL-L U <br /> S � V r%� ,. R�YFNNr <br /> l � Fp <br /> �j � 13 <br /> ?016 <br /> ACCEPTED BY: L- EMPLOYEE#: DATE: HY <br /> ASSIGNED TO: `,� EMPLOYEE#: DATE: �, <br /> NAic-( 7 -/.J• I. <br /> Date Service Completed (if already completed): SERVICE CODE: {r T, P/E: - ; <br /> Fee Amount: �<'� Amount P i �70. d—b Payment Date 7�3 <br /> Payment Type Invoice# Check# b !3 2— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />