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-- --C S�i <br />.AN OAQL 20UNTY ENVIRONMENTAL HEALI )EPARTMENT <br />• SERVICE REQUEST <br />Typepfi,Business o Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�j <br />f- A <br />OWNS I OPER O� <br />CHECK if BILLINGADDRESSE] <br />FACILITY NAME <br />SITE ADDRESS <br />[y^/j <br />/ <br />1 � //��/�'((/�//Jj/�//�,/ <br />('C� <br />19: <br />Street Number <br />t�eCtion <br />me <br />4" "' <br />e <br />Zi Code <br />HO E or MAILING AD RESS (If Different from Site Address) <br />! ` <br />Np <br />Street Number <br />t 5f?R1el <br />CITY% rn ok - <br />ZIP , -3 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />() Lf (P 69 ^e%J/ <br />PHONE #2ExT• <br />� '6_7 (03 <br />_ <br />BOS DISTRICT <br />LOCATION CODE <br />( 5) <br />CONTRACTOR / SERVICE REQUEST(`- <br />1 KEQI,= ` i OR 1 <br />. t I P114�E <br />F .I. E NA.ME� /% PH # /�. � �.r3- - T .— <br />cict;owledge that all site ancvor project S;)e:,ii' c I : iVttZ7Ni+hEt`TALHEALTH DEPARTMENT hourly harges asst1. <br />vi!y +gill be willed to me or my business +5t•c' er: t ,is forty <br />). c .fify.sat I have n .:L .OA <br />t , auul tllat 'lie work to .. ferfotT< <br />n ' • ralih;t?-:.�� C r . , ,,, idards; and F EDERAt law< <br />APPLICANT'S SIGNATURE: 44 j i &A- DAA E: <br />PROPERTY/ BusmESs OWNFR❑ OPERATOR/ MANAGER ❑ OTHFR AUTIIORI7-ED AC ENT <br />If APPLICANT is riot the BILLING PARTr, proof of authorization to sign is required Title <br />A�ITHORIZATION TO RELI'sASF 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 JOAQU:v COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it --ii(ake and at the same time it is <br />ov <br />prided to me or my repr- s::..a:.ve. <br />_ _----�p�l� — - -- <br />T) >` OF Si RV10E REQUESTED: <br />o i <br />I` � l SPN N��P PPR I <br />APPRO`VEO SY <br />J V\ <br />OL-1veI eA <br />Date Service Completed (if already completed): <br />i - - a;r10Urtt: -P 27 tib .�....., ...r �.. �.{ ��. D ( V <br />;.�r C.� r O - <br />Payment Type I 'r ic;.� # Check # l �� 3eceived By: <br />- — ZJ <br />EHD 4&01-025 <br />SERVICE REQUEST F09 <br />REVISED 6-5-02 <br />