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SITEApe5 <br />Streil Number 1 Direction I P. <br />CAJD t et m 6e /Ade,' <br />X <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />LAND USE APPLICATION # EXT. I APN # <br />— <br />EXT. BOS DISTRICT <br />PHONE #1 <br />1 <br />PHONE #2 <br /> <br />S?1,3 <br /> <br />LOCATION CODE <br />(72_ (-7— <br />FACILITY NAME <br />Zip <br />Crrv <br />OWI,RIS/PERATOR <br />441c-- letiar<-• <br />SERVICE REQUEST # <br />09) <br />CHECK If BILLING ADDRESS EJ <br />Tvoe of Business or Property FACILITY ID # <br />7/ 0 <br />4 4 y74 <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT --771,(Ayde <br />SERVICE REQUEST • <br />CONTRACTOR / SERVICE REQUESTOR <br />bidet:01 h)PIk( (663 bitC. <br />tkl <br />FAx <br />I <br />Cm( <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, ST E and FEDE <br />DATE: - 6 7 <br />If APPLICA 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 te, the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an at the same time it is <br />nrovirlerl to me or my reoresentative. IP r C i--k 1=1_4 Giiii (_o .....!-e-t c7-74-- _ — <br />TYPE OF SERVICE REQUESTED: apigiet &I fool itiipeche-Y\ . <br />COMMENTS: <br />REQUESTOR <br />BUSINESS NAME <br />HomE or MAIUNG ADDRESS 61)0 i\1 <br /> ci <br />121r\ <br />STATE CA <br /> <br />ZIP q006 <br />CHECK if BILLING ADDRESS Er <br />EXT. <br />3 I <br />APPLICANT'S SIGNAT AK/ <br />PROPERTY / BUSINESS OWNER U OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Bc.0 <br />PAYN • Et\IE.D <br />141A\( 1 s "57 <br />cousrl JoAclum <br />sv 1/4E ALE 1•1\11 koil op Ner AERNIve <br />ACCEPTED BY: L <br />EMPLOYEE #: c ?,-/ DATE: f-ic 7 <br />ASSIGNED TO: C--(..) C <br />EMPLOYEE #: c.,7 DATE: q c 7 <br />Date Service Service Completed (If already completed): I SERVICE CODE: / PIE: <br />Fee Amount: C,3-• Amount Paid OTh Payment Date s IkVb7 <br />Payment Type Invoice # Check # 5 I Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003