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BOS DISTRICT LOCATION COUE <br />C- PHONE #2 <br /> Err. <br />APN # <br />fer-)-17 <br />LAND USE APPUCATION # <br />PHONE #1 <br />SERVICE REQUEST # ,e 0-000 6 <br />FACILITY ID # Type of Business or Property <br />Lino kit-L <br />s 6.4)e-tic <br />CHECK if BILLING ADDRESS El <br />Movv444--, <br />q55 (p <br />Zip Code <br />OWNER / OPERATOR <br />( I Streel Number Direction Ci <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />ZIP <br /> el)FACILITY NAME <br />SITE ADDRESS <br />CITY <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> <br />622 <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR p)0(166th Voi3) cf}itc <br />P„111/42- e-tott-- <br />HOME or MAILING ADDRESS <br />fZirl <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 t e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, tani ds, E an1 I FE' : aws. <br />APPLICANT'S SIGNATU J r 44, DATE: 3j 02) ) 61 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER rilr OTHER AUTHORIZED AGENT 0 <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 />• provium LU IIIG Ul lily icin,a.A.Lu......: - <br />TYPE OF SERVICE REQUESTED: fqlakr erC fool (tillipethoi. . c (,),.../..Y.Lc crlivik/it)N T. <br />COMMENTS: RECEIVED <br />MAR 20 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY: C ) L ( u ,E ( ti—A. EMPLOYEE #: c, '2>-2_ 1 <br /> <br />HEAI nEpinTmErvr 7-4 <br /> <br />DATE: 3 ..6 0 7 <br />DATE: 3/2,E ; ( 07 EMPLOYEE #: C.) el Le, 7 ASSIGNED TO: C444Q-ce _cc_-3 <br />Date Service Completed (if already completed): SERVICE CODE: C.: Ce /‘ P/E:136_,, <br />Fee Amount Amoun c -3 / ... ,..7 At Paid Amoun t (.) S , (5\-) Pay Date T -., r1,110 T6-1 ii 1 <br />Payment Type ,/--- Invoice # Check # \ 0\ 0 l,„ S ,.. Received By. i_--, <br />EHD 48-02-025 <br /> !'8FeF-ORii (6old;Nod) <br />REVISED 11/17/2003 <br />;ENVIRONMLN i HEALTH <br />PERMIT/SERVICES <br />BUSINESS NAME <br />Crrv <br />(p- <br />STATE M- zIP (MIA: <br />P(ni <br />) <br /> _33 ,1 <br />Fax <br />(.1.)•3#) cc-S4 <br />CHECK if BILLING ADDRESS Er