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SAN JOAQUI0OUNTY LNVIRONNILNTAL REA.LODIWARTIVILNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST It <br /> G�5 5Tjq-r 10 /0 -7S7 5�0 <br /> OWNER/OPERATOR CHECK If BILLINGADDRESS❑ <br /> rap W, --6-r Con ST PRODUCTS I LLC <br /> FACILITY NAME Aa^D S5 # & 33S <br /> SITEADDRESS Lf SSS 1 ' TTA-TE Ff I0 [ l I STOCKT"OAJ asZUg <br /> Sneer Number Dlredlon Street Name Cil Zlo Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Lq C EIUT�12. 1'00! /.1'T� 1DR <br /> Street Number Strccl Name <br /> CITY L-A STATE n Jq ZIP '3 Vh1vZ 3 <br /> �Kl L V� 1� l� <br /> PHONE#I Ear. APN# LAND USE APPLICATION# <br /> PHONE#Z �p <br /> EXT. 13 DISTRICT LOCATIONCODE <br /> r CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR LOYLI FrZESH Ot,Lk CHECK If BILLING ADDRESS❑ <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> TWIT • SySTEAAS Alto S5'2 - oto <br /> HOME Or MAILING ADDRESS 3ZFax# <br /> �s3 �u�u �G OIZ . nIco F5sr latl <br /> CITY ,�IgNC. I� Q CO 1206 A STATE G-iq ZIP cl s "t q Z. <br /> BIL I ANG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent or same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to nm or my business as identified on this form. <br /> I also certify that ) have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FGDEIIAL laws. <br /> APPLICANT'S SIGNATURE: �j y .�1A DATtq: 6/7� ��— 3 <br /> PROPERTY/BUs1NE5sOWNER11 OPERATOR/MANAGER 11 OTHER AUTilotuzE.DAGENT IDI otwP1!(2 &1!0l—r <br /> tf APPLICANT is nar the BILLING PARTY,proof of authorization to.sign is required Title A <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, gcotechnicel data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMCNTAL 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: It <br /> COMMENTS: ✓1�IO�C.E I� $ WTEC.HJI}WCAL— Le Ai-eL 'Dt7-�E-C-7-o. I LD 2006 <br /> o m 1W9 $ `t l TU'12C31 isES . FSE 4 Zpp3 <br /> Li r--V-aWA C u l et 7 l RaweracceQ z I'PL 1 N� <br /> SpN`OpOP PL N PPH� IN501 <br /> PUB MENS <br /> APPROVED DY: EMPLOYEE#: r111i�A DATE: <br /> ASSIGNED TO: EMPLOYEE#: d Q C� DATE: <br /> Date Service Completed (if already completed): SERYICECODE: PIE: �3W <br /> Fee Amoun °� Amount Paid Payment Dale <br /> Payment Type Invoice If Check# Received By: <br /> EHD 40.01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />