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SAN JOAQUIN C.`OUNT'Y F,NVIRONNIENTAL IIEA1,T11 DEPAI2Tml.-Wr <br /> sERNACr IzrQcTEsT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> --. 47-'�e`P WA aA (i9/Z N.4NQ K Z64R xQ s W 1p ygR/Yl S/�y(�HECK if BILLING ADDRESS <br /> FACILITY NAME T— "`— <br /> rznk/AlZA cue NANAK PARKAsH <br /> SITE ADDRESS 14215- V-1 I 4 AA,,%/T L/A/�F- R r>. ?'RA(-y 95304 <br /> Street Number I Direction Street Name Cit Zin Code <br /> HON',E or MAILING ADDRESS (If Different from Site Address) <br /> E sffT L/rVE Street Number Street Name <br /> CIT7 STATE ZIP <br /> RA.0 CA .53 o <br /> PHONE#1 ::Ex i. APN# LAND USE APPLICATION# y <br /> 17Q-) a 8 7-03 -l 0 P - 1000.2 <br /> PHONE#2 Ext. BOS DISTRidr _.. LOCATION CODE <br /> 1 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> :RE;QUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUNAME PHONE# Ex T,. <br /> kovo i5 l= R rTCHARl7 N GCLT/NC 2 o <br /> HOME or MAILING ADDRESS 70! FAX# <br /> X5r5k p• u rrE. fve2 ( } <br /> CITY ,(f To STATE CA zip <br /> /"1 53510 <br /> BILLING ACKNOWLEI)GEIMENT: 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 app ' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COLNTY Ordincrtrce Co ofes,Standards, A' I and Ff:DE lags. <br /> APPLIC:ANT'S SIGNATURE: fKZ DA'rrt:�•: Ile-.3 <br /> PROPERTY/BUSINESS OWNER0 OPE[LATOR/A ANAGER El TBER AUrnoRizFD AGENT lJ <br /> !f.4PPLfCAA%T is not the R1[j NG P.'tRT't',goof of authorization to sign is required Tirfe <br /> At_11110RI7ATION TO RET.,EASE 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 enviromnental'site assessment <br /> information to the SAN JO.AQUtN COUNTY ENVIRONMENTAI HEALTfi DEPARTMENT 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:Q U M AI LI', H pA 14 O/c u lTs►!3/a! LANL,v�C/< EV/taW <br /> COMMS S: g I <br /> )t I f ' 4,t <br /> f t `` " OCT -- 3 2012 <br /> SM JOAQUIN CO KTY <br /> r °f - Y ° +. 7��!! ✓ EWRokhtENTAL <br /> HMT14 DEMRTW>7n <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: &I Amount Paid Payment Date !/ <br /> Payment Type Invoice# C�heck Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 �/� 4_.. �� -.� SR FORM(Golden Rod) <br />