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tr <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Type of Business or Property <br />«lse-v ,-flr vl;% -1 <br />FACILITY ID # <br />t 3i -,09-4 -- oo S <br />SERVICE REQUEST # <br />OWNER / BPerUTi <br />V,?,-,-p7 —_raz14Jc2✓R BILLING ADDRESS <br />FACILITY NAME <br />�' �- �F,V�r�'/✓L �%` ���7R✓�G� <br />SITE ADDRESS 3ii3O <br />Street Number <br />llZi/ff <br />Direction <br />i /�/�2 1*7-e-C%�/ AD <br />Street Name <br />�iCJ%tG`7 <br />Ci <br />/ 5'-? 7 7 <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) ell <br />Street Number <br />�ZEL�r(J/t/ %* 1/C <br />Street Name <br />CITYS,&z, - STATE C� ZIP Q � p c <br />V �`� 7-o5 <br />�3 <br />PHONE #1 Exr• <br />('90) 4161f - 3Gqb <br />APN # <br />2 S 3 ®3 ® ,r® <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />t ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR owl cA�e eAbeeaLL <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME ��� i/?��I��� C���"'��4/ W® <br />( /y <br />PHO <br />7�IV <br />I7GmC9r MAILING ADDRESS�e ® rte- � / G <br />I 0 <br />(�0 Q) <br />f <br />� / ® ,,,, �® 7 <br />dZip <br />CITY V Ie- /r0 STATE <br />STATE <br />� <br />54 <br />�9 <br />BILLING ACKNOWLEDGEMENT: 1, 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 i <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 FE RAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />yyy ` o 7 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 10'-'V10'emle- <br />If APPLICANT is not the 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: A M4 IA l 9CR� I % <br />SEW- R 3 <br />:7�1w egg,*j / <br />ACCEPTED BY: �a. ®/ �G���� <br />•�C�ri. �i <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: /l <br />Date Service Completed (if already completed): 1112-,910 '7 <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />M <br />