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SAN JOA(,,,I COUNTY ENv-gttONm NTAL HEAL' EPAR"I NIRNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILir/IIJ# "= SERVICE REQUEST#' <br /> OWNER) OPERAT <br /> ' •/Y7� CHECK H BILLING ADDRESS <br /> FACILOYNAME .� U <br /> k frerz e <br /> SrrE ADDRESS 3�? <br /> Street Nun War pjr?alon ! ` �/ - Strad Name � `-/ca, <br /> C A <br /> HOME or MA NG A007R (H DiHennt from Site Address) / <br /> /rtILA <br /> L Street Num3ar 3Vaat Name <br /> CITY � 1ATE ZIP <br /> (_i5`t 7 <br /> PIIQNE 1 - EXT. APN# LAND USE APPLICATION# <br /> PHONE i@ Ex. :3CSIDIsrxta' ` -CAT!CN C:,CE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECKIT BILLING ADDRESS LJ <br /> I BusiNEss NAME 1, 1� p _ Ezt. <br /> HOME or MAILING ADDRESS // FA%# "v/J'CYSJI <br /> CITY STATE ZIP ;7 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, Operator or authorized agent of same, <br /> acknowledge that all site andlor project specific EV4TROMAENT_A;.EJF-AL.TH DEPARTV!]EYT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified an this form. <br /> [also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQLTN <br /> COUYrY Ordinance Codes.Standards.STATE and FEDERAL laws. <br /> APPLICAL`IT'SSIGNATURE: _ DATE• -O�O "f> `f <br /> PROPERTY/BUSINESS OWHERCI OPEILITOR/IAGER OTRERAUrftOR1ZEDOTRF.R.IOTRORrIS.D�1GE:rr���� <br /> lf,dPPLic.-tvT is net the B¢LGUG P. of of authorr.:ation to sign is required rtUv <br /> AUTHORIZATION TO RELE,-ISE I14FOR14IATION: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 enviromnemal/sue assessment <br /> information to the SAN JOAQLLN COL\TY ENV[&ONbMNTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ktowvjal W <br /> CGMYENi9: qAl) uIVs <br /> I - <br /> =�D 48-01-025 SERVICE REQUEST=ORM <br /> <EvISE �-JA <br />