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4Z � RT ENT <br /> SAN JOAQUIN COUNT NVIRONMENTAL EALTH PA <br /> SERVICEI�EQUEST <br /> Type of Business or Property FACILITY ID# I�SERVICE REQUEST# <br /> p \r -- - �Ce O SIZ007 %/ 2- <br /> OWNER/ <br /> - <br /> OWNER/OPERATOR <br /> (V cJ. n h CHECKIf BILLING ADDRESSO <br /> FACILITY NAME ^ 2\ CA 5e1,Zv'\CE v�fJa�(7tl � C fejfl�2(1Ce bQ�' <br /> SITE ADDRESS r ,f`\r� SOVy^weyyC�A & r��ry�� M �`✓�(`�/�V <br /> Street N�r I Direction t�5[eee pNa�m C �� ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 391 v <br /> Street Number Street Name <br /> CITY �^ STATE GA zip^� d 525 ^ <br /> PHONE#1 \ Exr. APN# -eOR 'L� On LAND USE APPLICATION# l• <br /> (aCA) -740-5500 ak(0- 06P0-015 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) 0o y <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> GtC1R�s QjRO W(1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em' <br /> �M �es� C ecru 'Ic�T aa�- 1 noti <br /> HOME Or MAILING ADDRESS FAX# <br /> u 5 <br /> CITY G Lq- STATE C' ZIP a�l�.0LA <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operat`or or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTTi DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 an FE la-ws. <br /> APPLICANT'S SIGNATURE: —�'d ----- DATE: �31?1I1V <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTU (T t �/ tPr•4/� <br /> (fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or�C for of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical dat ' onmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it iS av � f� a same time it is <br /> provided to mey representative.WthhII, <br /> CE EOUESTED: Icy AN <br /> COMMEN S: <br /> MAR 7 6 2018 s kIl°gaulNo <br /> ENVIR NNIENTAL HEALTH y��TyOFpgRM <br /> EPAR'FMENT Flyr <br /> ACCEPTED BY: Al <br /> EMPLOYEE#: DATE: 3 Z-Q <br /> ASSIGNEDTO: Sri EMPLOYEE#: l DATE: 3121Knl I� <br /> Date Service Completed (if already cordpleted): SERVICE CODE: �23 11E: <br /> KI,^tO l <br /> Fee Amount: L.1SL� Amount Paid [.,(� Payment Date 3 lS1 <br /> Payment Type Invoice# / Check# Ig Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> QRO54keo-12- <br />