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SAN JOAQUIN COUNTY ENVIRONIWN1'A1,1tFA1,TIT DIEPARTMLN'I' <br /> SERVICE REQUEST _ <br /> Type of Bus(nass or Property FACILITY ID# SERVICE REQUEST# <br /> C.�V=IFS <br /> -SD <br /> _ _--- S_ CJikII� _ <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> �T�2f3Lt('A1 l..ky�FEP Cc>h11?AVY __ _-- <br /> FACILITY NAME <br /> SITE ADDRESS <br /> tivrnl lf�imher DNacllon <br /> HOME or MAILING ADDRESS (If Different from Site Addrosa) <br /> s r..+Numhnr NAM <br /> CITY ..__ STATE n ZIP <br /> �ou4-TAIN A i 01 µ <br /> PHONE#1 E'er• APN 9 LAND USE APPLICATION# <br /> I I <br /> PHONE 92 EXT BOS DISTRICT LOCATION CODE <br /> 1 } <br /> CONTRACTOR/ SERVICE RE,QUESTOR <br /> REQUESTOR ��1�17��rJ CHECK f(BILLINGADDRESa� <br /> PHONE# E— <br /> BUSINESS NAME I�'{�yY `N C• -3\p _ `-p2S0 w <br /> FAX# <br /> HOME or MAILING AODRE,SS 1 } <br /> IqVol-1 f 1- l/E <br /> CITY STATE Z1P C105D l <br /> RIT 1 TNG ACFCNQ-)W-,F.DGI,tiII ET1T: I, the undel"signed property or business Owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONh1CNTAL JIFALT14 DEPARTMI NT hourly charges associated with this project IQq y t, <br /> or activity will be billed to me or my business as identified on this form. n1 <br /> I also certify that I have prepared this application and that I work to be perfumed will be done in accordance with ail SAN JOAQUIN �CF�`'T <br /> COUNTY Ordinance Codes,Standards,STATE and I_laws. G tom!' �,, f <br /> APPI-ICAN T'S SICNATIIRF.: DATE: Suu l o HNCOO <br /> , 1�rVL �tytl(...t� fq�8T V7-l- <br /> PROPERTY/13USINESS OWNER❑ 1')]IATUR/MANAGER ❑ <br /> OTHER AUTHOR I'LED AGEJyT �A <br /> I,fAPPLICANT Lc not thPART7,proof OfauflroriZation to sign is required Titre A'l <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 environrnentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY F.NVIR(INMF.N,"AI.HL•AI,rR DrPARTMENI-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: <br /> T• _ <br /> ro it-sCk)Dt�i Pg(Z-ffTiOn-1 VIA \1SI Ligi���rJc� r NtEcrtr}iCrQL � �." ," � L�"S./• � <br /> �� r.Ic-cOL�. Sj}9r�vc�cr DoCs`J •vls�,, �) J�E� f1N-) FOc�.o ��'�'r=�_ ti�v�� <br /> ACCEPTED BY: ♦ e EMPLOYEE IO: DATE; -l �f <br /> ASSIGNED TO; <br /> EMPLOYEE#: DATE: <br /> Date Service Completed f already completed): SERVICE CODE: PIE: t(DO t <br /> Fee AmouAmount Pai / �D� Payment Date 9 r <br /> Payment Type Involce# �f Ch96 Rec ived By: <br /> EHD 413-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 n <br /> q- H-7 - nY�t V C( �I� Cc � e <br />