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I SAN.JOAQUIN -)uNT`Y.ENviRoNMENTAL,HEALTI'EPARTMENT <br /> SERVICV REOU,EST <br /> Type of Business or Property FACIUTY ID# SERVICE REQUEST# <br /> Sp-ut) s l <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS Q <br /> FAcilrn NAME <br /> SITE AADRESSLI '1 -22-0 rJ�' '�' <br /> Street Number Direction Name- C' Zip Code <br /> HOME or MAMNG ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 + Ezra APN# LANh u TWN# <br /> PHONE#2 Ext. BOS DISTRICTIMCODE <br /> LocaT -'` <br /> ) ' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> GNECK i(BIt1tNG ADDRESS <br /> sNAi�E PHONE# <br /> BuslNEs <br /> 30� 955~'r 7S'ExY. <br /> HoMii or MAa iNG ADDRESS F 0 <br /> z-a j) -3 f 2 37-3 <br /> CITY 04'ST'ATE ZIP L�?S-2-I.3^ <br /> BILLING-ACKNOWLEDGT,MENT: I, the undersigned property or business owner, operator "or authorized agent of same, <br /> acknowledge that all site andlor'projectspecific EwiRoNm NTALHEALTHDEPARTMEmrhourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> I alsa certify that I have prepazed this application and that the work to be performed:will be done in accordance with all SANJonpuTx <br /> CQUNTY Ordinance Codes,Standards,STATE and FEDERAL la <br /> APPLICANT'S'SIGNATURE DATE: <br /> PROPERTY/BusuvEss OWNER❑ OPERATOR!MwNA.Gt3t 11OTuER A[mtoRizED AGENT <br /> IfAPPLICANT is not the BH.LrNG PA R7T,proof of authorkadon to signs required Title. <br /> AIMIORIZATION TO RELEASE 1NFORMAnON:When applicable,I,the owner or operator of the property,Jocated at the <br /> above site 'address, ;hereby authorize the release of any and all results, geotechnical data andlor environinental6ite assessment <br /> infaunatio>a to the SAT+I JoAQufN CouNt X ENviRONi4WAL,HEALTH DEPARTMENT as soon as it is available and at sanie time it is <br /> provided to me or my representative: <br /> TYPE QP SERVICE REQUESTEa: �'vyes JtsF:f .,Si r � I` cr7U �YMENT , <br /> COMMENTS:, <br /> -DEC12, 2005 <br /> ''° <br /> AN JOAQUfN COUNTY <br /> ENVIRONrvIErvTA <br /> HEALTH DEPARTMENT' <br /> � <br /> .ACCEPTED BY: EMPLOYEE,#: DATE:, �( 1 �zr/cs <br /> ASSIGNED TO: t"t !1 t EMPLOYEE*: �y DATE: Z ?.f C) <br /> Date Seivice Completed (if already completed): SERYI E CODE. -2 P E: � T a•• t <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Involve# C6k# li(7 i j Received By <br />