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SAN it9 AN COUNTY ENVIRONMENTAL ftme .I DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST III <br />es'derT%; a! <br />COMMENTS: <br />OPERATOR <br />EMPLOYEE #: <br />DATE: <br />g�/�� <br />'t <br />=AciuryNE <br />CHECK If BILLING ADDRESS® <br />jl M <br />Date Service Completed (if already completed): <br />— <br />SREADORESS g'6sn <br />Imen6T �4a� <br />Tracy g537ta <br />Street Number Direcaon <br />Slrea^t a o <br />C code <br />HOME Or MAILING ADoms (If Different from Site Address) <br />invoice # J Ji <br />CITY- �R j <br />( <br />Street Number <br />ti acreet Noma <br />STATE zip <br />I. <br />PROREIN ExT <br />( `141-14- Q181 <br />APN # <br />M 1107-H <br />LAND USE APPLICATION # <br />PHONE#2 EiT. <br />( 1 <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />kali'> Pr <br />Business NAME -- ri c- C LLQ <br />HOME Or MAILING ADDRESS 1' <br />CITY �1`1> 1 1 „ ' - - <br />CHECK If BILLING ADDRESS la <br />y- 98)8 <br />zip ? <br />BILLING ACKNOWLEDG'kMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DhPAR:imF.NT 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 appf tion and that the work to be performed will be done in accordance with all SAN JOAQuIN <br />COUNTY Ordinance Codes, Standards•, T and FEDERAL laws. <br />APPLICANT'S SIGNATURE: v (� DATE: <br />PROPEWIT/ BUSINESS OWNP.R19 OPERKI MANAGER❑ 011 -HER AUTHORIZED AGENT f��l <br />IfAPPL/CANT I.r not the Bium PARTY rymof 0f antharlZation to Sign i3 required 7'irlr <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 DEPAR'rMENT aS Soon OS it is available and at the Same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: p l ®V mdex1roundC <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED To: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SEiRACECOOE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />PaymontType� <br />invoice # J Ji <br />Check # _ <br />Received By: <br />EHO 48-02.025 SR FORM (Golden Rod) <br />REVISED 1 1/1 712 0 09 <br />