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01/18/200 17: 11 2094683433 FIFTH FLOOR PAGE 02 <br /> r <br /> SAN JOAQUIN C(,�ATY ENVIRONMENTAL HEALTH D>c_ARTMENT <br /> �,�� � ,����y•' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN R PE TO �� CHECK if BILLINGADDRESSE] <br /> FACILITY NAME /I � (t U r j q D� <br /> SITE ADDRESS �l `I lG� <br /> <- .�L�C�tDrV 95x0`� <br /> Street Number Di coon eet Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (7ry )67v-5 ao0 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ StRVXCE REQUEST01� ' , c <br /> REQUESTOFt CHECK if BILLING ADDRESS <br /> BUSINESS NAME r-- •„/ /�/- /—�O/, PHONE# a. <br /> HOME or MAILING ADDRESS ��t� �� /i,�- Fuc# <br /> CITY / of;, L!2,- <br /> �Q��� STATE I ZIP UU� <br /> BILLING ACKN EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all'Site and/or project specific ENvixo MENTAL HEALTIi DEPARTajENT hourly charges associated with this project or <br /> 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 JbAQUrN <br /> COUNTY Ordinance Codes, Standards; S A E and FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE: i,F�/��it <br /> PROPERTY/Busmr•,Ss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANI'is not lheB1LLWGFARZY,'(lroofofa.uthorization 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 ENYIRONME-NTAL HEALTH.DEPARTMENT as soon as it is available and at the same time it is <br /> provided to nie or my representative. <br /> TYPE OF SERVICE REQUESTED: IF <br /> COMMENTS'. to �fC�(,f��i�•!l-r✓ /CSC!�/L--1//��� y ✓ <br /> D lila/ <br /> �l ll G <br /> N PQM, <br /> ACCEPTED BY: EMPLOYEE#: 7 DATE: -44 ' O <br /> ASSIGNED TO: G EMPLOYEE#: 2 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE; j PIE: 2 36 <br /> FeeAmount: Amount Paid. (� l�_S� Payment Date <br /> Payment TypeI/ Invoice# Check# 12�� Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br />