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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />RINNIAHARM <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / 8PE1tAT61i _ _ <br />BILLINGADDR7® <br />i✓ <br />(/�_`j� <br />FACILITYNAMEe�TR4.4 t c U� � /%/7/` ���� C�.+� <br />SITE ADDRESS 211307H- <br />Street Number <br />Direction <br />e�i elly' GCJ?�l �D <br />I Street Name <br />7A71# -e— -1 <br />city <br />/ S 3 77 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address)�c7W2'6e <br />Street Number <br />/i / <br />Street Name <br />CITY G �... / STATE eICd ZIP <br />R- 7 <br />PHONE #1 EXT. <br />(,�?Oli -�I6e <br />APN # <br />090 !O <br />LAND USE APPLICJATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , `/GSL �L <br />`✓ <br />/ <br />COMMENTS: ISRI U I/1 � Ay'C A� 1I /, z-ro <br />Arl e- R&49?il1/,!� <br />2 i97—� <br />44 ,7, <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME � JQui� Cp ' jr02'® <br />,,r�� ^ <br />w,gsr <br />PHONE # <br />-J-4 <br />EXT <br />—3 o b 6 <br />Neitic-or MAILING ADDRESS <br />p� ® Su?e /k/L <br />FAX # <br />('209) <br />tqf7� <br />CITY ��� �(J�t/ STATE <br />6:4 <br />ZIP �►' C 2-07 <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 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 SIGNATURE: , DAT���Eyyy ���p7�_ <br />PROPERTY / BUSINESS OWNER ❑ 7 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ��+ �`/d el pll e <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 />/ <br />COMMENTS: ISRI U I/1 � Ay'C A� 1I /, z-ro <br />Arl e- R&49?il1/,!� <br />2 i97—� <br />44 ,7, <br />ACCEPTED BY:� <br />EMPLOYEE #: <br />DATE: ��Q�/� <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): /©2 � 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 />