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r SAN JOAQU. OUNTY ENVIRONMENTAL REAL L EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C Gn.%,1 ,4CIA&j� IpElZo o,�-9.� <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br />' FACILITY NAME <br /> SITE ADDRESS <br /> ! 7a�o f�EivRy RoAI� sc,aco�l ?s3aQ <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Streel Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPUCATION4 <br /> ) 333 - 7a-76, as - 7 62- 54 1E21V A t 3 <br /> PHONE42 Ex T. BOS DISTRICT LOCATION CODE <br /> fi CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT, <br /> G,yc—snN,5 GeOAlSu4 T//V f <br /> HOME or MAILING ADDRESS FAx# <br /> F. O. Lax 37 f 164,93 -zsy8 <br /> CITY t/f� STATE eA ZIP �R <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HGALi'm DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicat' n and that tl work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slanclarrls, STA"' d FE <br /> APPLICANT'S SIGNATURE: DATE: 11- 6—a3 <br /> PROPERTY/Rt1S1NFSS OWNFIt❑ OPERATOR/MANAGER ❑ OT1 -R A1JTIIORIZFD ACFNT <br /> If APPLICANT iS not the BILLING PARTY,proof of atrthori anon to sign is required Time <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUN'rY ENVIRONMENTAL HLALTH DEPARTMENT as soon as it is available and at the same time it is <br /> I provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Q(RF•hG,0_ u0WRFAG-1'7 CONTaMJNATrarl REPO r <br /> 4 COMMENTS: RECLl <br /> G ZV <br /> CINA.llftgl <br /> CP U SA � NtpAE�M �T <br /> L'TH D�PA� <br /> APPROVED BY: r„ EMPLOYEE#: G� 8 DATE: <br /> ASSIGNED TO: _ ���� � V V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: Z0473 <br /> Fee Amount: l e6.OC) Amount Paid DU Payment Date <br /> i Payment Type V Invoice# Check# �� Received By: �'� ✓ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />