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SA JOAQUIN Co TY E VIRO ME TAL HEALTH DEPARTME T <br />SERVICE REQUEST <br />Type of Business or Property FACILITY 10 #SERVICE REQUEST # <br />~~()h7/-~<\OWNER I OPERATOR <br />~~~~/~CHECK if BILLING ADDRESS0~~<' <br />FACILITYNAME <br />SITE ADDRESS <br />Street Number I Direction I 4r=r«:N~Ib~tv 1;9~~t7/1'7/0 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number I~~Street Name <br />CITY c,/L A.A"~STATE ZIP~'Y( <br />~19'_//8/'-2-93T./I AP~/Of/ltjt "q LAND USE APPLICATION# <br />PH2!h <br />EXT.'",BaS DISTRICT "LOCATIONCODE(~72-'7-(!///.s- <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />~/1 A~£?CHECK if BILLING ADDRESS0 <br />BUSINESS NAME .>::PHONE#EXT. <br />() <br />HOME or MAILING ADDRESS FAX# <br />() <br />'"CITY STATE ZIP <br />BILL!G AC OWLEDGE 1E T:I,the undersigned property or bu iness owner,operator or authorized agent of same, <br />acknowledge that all site and/or project specific E 'VIRO 1'.110 1 AL HI:Al TH DEPART 11::T hourly charges associated with thi project or <br />activity will be billed to me or my busines as identified on this form. <br />I also certify that I have prepared tlus application and that the work to be performed will be done III accordance with all SA JOAQUIN <br />COl'TT"Ordinance Codes,Sfal/dards,~and FEOERM law.~~ <br />APPLIC 'T'SSIG AT RE:X ~~~d'~DATE:4/9--//'" <br />PROPERTY 1 Bu INI::SS OWNER 0 OPERATOR 1 I\IANACEll 0 OTHER A(ITIIORIZED ACENT 0 PA,h <br />I,,'.I B P .r.r 1 •••••I .iMENIJrlPPLICANTISnotfIefLUNGARTY,prooj OJ authorization to Slgll IS requtret TlReCEIVED <br />AUTHORIZ TION TO RELEA E 1 FORMATION:When applicable,T,the owner or operator of the prAtiSty,l9.cated at the <br />above site addres hereby authorize the release of any and all results,geotechnical data and/or enviro~tfNsttdi a2Dllment <br />information to the A JOAQUI COUNTY E VIRO r [ENTAL HEALTII DI'PART iF T as soon as it is available al1d~~Wt-~ame time it isJlQlJllrCOUNT'rProvidedtomeormyrepresentativeENVIRONMENTAL.,HEALTH DcPAR <br />COMMENTS: <br />~~!!Ep ~1?J1?o <br />t~C~IIq) <br />t <br />TYPE OF SERVICE REQUESTED: <br />Fee Amount:Amount Paid <br />c5~FORM (Gold n Rod) <br />ACCEPTED By:EMPLOYEE#: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Payment Type <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />~~(~~)q$3~76~7 70 <br />,/~N.I