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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 />:1/4t CV( <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT 0 OPERATOR / MANAGER <br />SAN JOAQUIN 7.:OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />2 2 <br />SERVICE REQUEST # . <br />,r/ 5? 005 . . . V.3.- . . t. <br />OWNER / OPERATOR S o CHECK if BILLING ADDRESS <br />FACILITY NAME <br />{) 2,fi'// VA f C92 PA <br />SITE ADDRESS Akl?19RESS <br />Street Number .:3‘,,.1If Direction <br />/Y1:76 4:Pr' : :4 , <br />ifeardifee Stre. Name <br />filie ‘110 71 <br />City <br />71;71 / Zip Code <br />HOME or MAILING ADDRESS If Different from Site Address) <br />Street Number Street Name _ <br />CITY STATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Exr. BOS DISTRICT <br />-2 <br />LOCATION CODE <br />/ <br />NTRACTOR / SERVICE RE UESTOR <br />REQUESTORO <br />414 <br />i <br />a 44416.., <br />CHECK if BILLING ADDRESS Er <br />BUSINESS NAME <br />4/09t9/ <br /> <br />,:27g/;'- <br />PHONE # <br />C.' ).3ii . -di <br />EXT. <br />HOME or MAIWIG AD)DRESS <br />-21o? P, <br />Fm# <br />( )3/622) p.A/ <br />Orr <br />1/490445/1,Paefew <br />STATE 4(c ZIP <br />BILLING ACKNOWL DGEMENT: 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, Standards, STFE d FEDERAL laws. <br />APPLICANT'S SIGNAT DATE: 57, - 722 <br /> <br />TYPE OF SERVICE REQUESTED: It 6 6 Yr i0 /CPO Re.MiCt PA YA4 ENT <br />COMMENTS: <br />!?O NOT rISCAlia-Nvj°1F1QuIN <br />1 • EIVED <br />MAY 1 1 !fa <br />TH 8P,MEN7-qj FY L.. ,ARTmENT <br />ACCEPTED BY: 7/12all/A., EMPLOYEE #: ,},,, DATE:5/4/ /0 <br />ASSIGNED TO: <br /> 1 t/79-ednAikit <br />EMPLOYEE #: / . ,1 i 3' DATE: /If / 0 <br />Date Service Completed (if already completed): SERVICE CODE: c5.0...,... PIE: <br />Fee Amount: W 2_36 , et) Amount Paid <br />OR -I P - <br />Payment Date 6/ (A / I 0 <br />Payment Type 6..„...-- Invoice # Check # S t q.) <br />Received By: N-g, <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003