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ply g($ totl atew� <br /> SAN JOAQUINOUNTY ENVIRONMENTAL HEALTI i DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or —n O� IL`L FACILITY <br /> Aq �11 <br /> O I <br /> Owner/Operator <br /> OP W 6 5'T Co v:v S? P R O D UC G T5 r LLC. Check if Billing Address <br /> Facility Name A P1 0 d q(0 O 0 <br /> Site Address � 2 6—o N (,J Vt)C K " N c'SZO Z <br /> Street Number Direction S" Name / City Zip Code <br /> Home or Mailing Address(If Different from Site Address) <br /> Sireel Number Street Name <br /> City State Zip <br /> Phone#1 2)t1'e7 Ext. APN# Land Use Application# <br /> MM Lf(o!57- 15'55-'T <br /> Phone#2 15 tO Ext. BOB District Location Code <br /> M'A fo <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Requestor Lop, JCRESH� <br /> Check if BILLING ADDRESS [ ] <br /> r u � <br /> Business Name Phone# Ext. <br /> TA17- 4EE:5polV . (` 110 ) $ 8- 101D <br /> Home or Mailing Address FAX# <br /> ,;2-83 L u (A FU G. fl R c ) <br /> ity State Zip <br /> RANG" CORD0IJA C4 957 Lf 2- <br /> BILLING <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, <br /> Acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT 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 application and that the work to be performed will be done in accordance with all SAN JOAQUtN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /!K% Date:-3—it-63 <br /> PROPERTY OWNER/BUSINESS OWNER[ ] OPERATOR/MANAGER[ ] OTHER AUTHORIZED AGENT ] <br /> If applicant is not the BILLING PARTY proof of authorization to sign is required. f 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and�7 me it is <br /> provided to me or my representative. nn r RR e 1 I <br /> .kl <br /> Type of Service Requested: P,E-PI0. Cell (� RQ p Tur`✓�� PE►Q STIKb Z 'T6�"P4 <br /> Co to Lo (a IS 45 c( 1 o d:' MAR 19 2003 <br /> Comments: -b PTE d 1=7 T _ 3— 15 — 0 ,3 6ANJOAQUINCOUNTY <br /> PLBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Approved by: Employee#: 2ZY L Date: — 19 -3 <br /> Assigned to: Employee#: 3 Date: l <br /> A�Qate Service C&mpIet9d(If already completed) Service Code: [Ct. P/E: 'Z <br /> qp�e Amount: Amount Paid . Payment Date: 311 D 3 <br /> Payment Type ✓ IInvoice# Check# a Received By: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />