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JAM JOAQUIN 1..OUINI V LNVIRONMEN'I AL[ZEAL 1'H ObrAKI MEN-1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDR SERVICE REQUEST M <br /> OWNER I OPERATOR Fte-N t C po m <br /> CNEat'rf BILLING AtIORESS <br /> FActurY NAME PorA-bo <br /> SITE ADDRESS2L0310 s. a+ti�A F—C> <br /> Strwl 'u I of on t C <br /> m6 - <br /> HOME or MAILADDRESS IN owerent from Site Addreim) I`�-SS l�. I '-Ch 5-F <br /> street Number ft. <br /> CITYTfZhcy STATE C� ZIP <br /> PHOME#1 1 �* APNf LAND IISE AP ATION8 <br /> I zoq) fi3S- '+9 Y9 zS'�-- ISo -ro P� - 12vo a35 <br /> PHOME#2 En. BOS 019111[ T LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �t3 ay QA,L Gel CnecR H BRuNG ADDRESS❑ <br /> MESS NAME Err <br /> BUS <br /> L.Is1C r)ftk G-t�EnNIRoA�n1ENTAL Req 3(05- 03-45 <br /> HOMEor MAILINGADORESS �t0,} (n.1 . Othl.�_ ST. F"# foct_ 03�13 <br /> I Z07) 3 <br /> 0- STATE C A ZIP I rX40 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authori7A agent of same, <br /> acknowledge that all site and/or prOJect specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project <br /> or activity tvill be billed to me or my business as identified on this form. <br /> I also cer ity that I 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,STAT 'lrTfl FEDERALfyws`� <br /> APPLICANT'S SIGNATURE: ��j/il�� DATE: G,Vj as/O?0/3 <br /> PROPERTY/BUSINESS OWNER111- OPERATOR/MANAGER ❑ OTTIERAIrTNORiZED ACevr❑ <br /> Jf APPL/C4,VT is not the B¢LA'6 PARTY.proof Df authorization tO Sign IS required Title <br /> AUTHORIZATION TO RELEASE 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon as it is available and at the s��t�rJ{e it is <br /> provided to me or my representative. e/Ir/sr <br /> TYPE OF SERVICE REQUESTED: A-C4tCIN Soft- $Jf'-MBIL_r7-Y S'TUDy Ill D <br /> Com SqN J 5 20'3 <br /> y/a 9 ' Qc"' `Rc/'� ays) 'frf lNti p ME O Il' <br /> T <br /> TAC <br /> ACCEPTED BY; r , ,N` EMPLOYEE O: Z(n7 0 DATE: 4- L 7 I <br /> ASSIGNED To: �Cd _ EMPLOYEE A: 5_ DATE: Y. / '3 <br /> Date Service Completed (d already completed): SERVICE CODE: s 2 Z PIE: /b G I <br /> Fee Amount: Z �-b Amount Paid ;L56.VC) A_ <br /> Payment Type Invoice N Cheek aY /��G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED IIn7/2003 <br /> I <br />