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SERVICE RE' Q EST <br /> ' Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR IS A <br /> CHECK if BILLING ADDRESS D <br /> FACILITY DAME <br /> ,-rrE ADDRESS 2 J�J ,'\ I / e m / J'1 Z-D� <br /> SlrccSZ u <br /> Stroot Number Direction l NameCll �21 Codc7 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION IE <br /> PHONE 112 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRAc m i SERYQcr REQUEs-rOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> EIUSINESs}NAME PHONE i1 EXT. <br /> /aZL <br /> HOME or MAILING ADDRESS FAX It <br /> J (2 0) 365' 3 <br /> GIN / D STATE �/t ZIP <br /> BILLING ACCCC...IKNOWLIsllGEMEN'I': I, the undersigned property or business owner, operator or authorized agent: of Same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMGN'1'hourly charges ,ISSOCi iLed with this project <br /> 01-aetivity will be billed Lo me or my business as identified on this I'onn. <br /> I also certify that I have prepared this application and that the work to be perlormed will be done in acc0rdancC with all SAFI.10A0U1'.0 <br /> COUNTY Ordinance Codes,SlunclarelY,S•rATE and FEDERAL laws. <br /> API'L1CAN'r'SSIGNATURE: DAw: <br /> PROPEIVI'Y/BUSINPSS OwNI'.It❑ OI'F.RA'1'0R 1ANAGIiR ❑ OT'Hlilt AirniORiLIiU Ar i.,N'r❑ — <br /> il 1 PPLICdNT is'unl the BILLING PARTY,proof of authori ation to sign i.s required Title <br /> AU-I'I-LORIIA-rION TO RELEASE INFORMA"CION: When applicable, I, the owner or operator of(lie property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data anti/or environmental/site assessment <br /> information to the SAN.IOAQUIN COUNTY ENVIRONMENTAL I-IHAL'1'll DEPAR'I'MGNT as soon as it is available and al the same.time it is <br /> provided to Inc or n)y representative, PAYMENT <br /> TYPE OF SERVICE REQUESTED_ f RE <br /> CEIVEU <br /> COMMENTS: (/ OWN g 2005 <br /> . <br /> SANNVIIRONt <br /> N COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE'i#: DATE: <br /> ASSIGNED TO: t EMPLOYEE it: DATr:: 8 <br /> Date Service Completed (if already completed): SERVICE CODE: ley 9 <br /> PIE: <br /> Fee Amount: ;?- Amount Paid � �� Payment Date ti Q-JD L� O <br /> Payment Type ✓ invoice It Check 9 Received By: <br /> EHD 48-02-025 SR FORM(Gr)Iden Rod) <br /> REVISED 11/17/2003 <br />