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"N YlAkUkNlYiLUN 1r1LL.xxl,/1L1'11 JU.Li 'AXIIVILN 1 <br /> W SERVICE REQUEST 1 <br /> Type of Business or Property ..::SERVICE REQUEST':# ' <br /> � <br /> fs, OWNER I OPERATOR CHECK If DJUNO ADDnEss❑ <br /> t' <br /> FAcam NAME <br /> 9ftE ADDRESS r cw �—�•�.. `�, <br /> w .� <br /> o. 5 <br /> Z� heel N mbeSt lot Named <br /> " ! HOME or MAILING ADDRESS (If Different from Site Address) . <br /> STATE . ZIP <br /> . .. CITY �] <br /> PHONE#t ExT. APN#. LAND�Use�A�PvttcanoN# <br /> F PHONE#2 Exr. ;GOS;t){S RICL Sw;rwl+'+re .6I'OCA*6R''C6Uj,f$1 %11 . <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> tK REQ ESTOP, CRECKIt Aov sL:,� <br /> BUSINE 5 NAME PHONE# <br /> iioME or Mwurlc ADORE <br /> FAx# <br /> F <br /> ECIT STATE zip q �� <br /> v� D G <br /> JaI <br /> LLI ED EMENT: I, the.undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMEN'tALHEALV DEPARTMENT11011171Y charges associated with this project or?'•'h^; <br /> ` activity will be billed to me or my business as identified on this form <br /> C .. I also certify that I have prepared this application and that the work to be performed will,be done in accordance with all SAN JbAQutN <br /> COUNTY Ordinance Cortes,Standards,STATE and FEDEttA aws. <br /> I' APPLICANT'S SIGNATURE: DATE: 4qj .'..t <br /> PROPERTYIBUSINEWOWNER� 8RATOR/lYtAtIAGER ❑101rZation <br /> IIERAUTRORIZEDACENT❑ ^ <br /> IfApPUGiA+Tis not the proof of to sign is required Title <br /> UTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or'operator of Lite 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 /> infer ation to the SAN JOAQUIN COUNTY'ENVtRONMENTALHEALTEI DEPARTMENT as soon as,it is available and at the same time it is <br /> provided to me or my representative. <br /> a!-.. TYPE Of SERVICE REQUESTED'.• G iTj /�t7 <br /> COMMENTS: PAYMEN_t <br /> DEC <br /> .. :. PIAN JC)AQUIN CC13Nf`I <br /> .:y PUBLIC HEALTH 5EnMEB <br /> Nlk HEALTH DIVIBI4N <br /> .. <br /> APPRbVED 9Y: l:MPLOEIMP <br /> E <br /> `l 'A551GNED.Td:• ... .. . •. _. . :EMPL01�Ey�' t�i�/ .'DATE' l� ���r�Z 'i d <br /> ` qq Dato Seivicd Completed.{if'alreadycompleted}: SERVIGECot3E; �L� P.IEp/ <br /> i f+ae'Amotint• 70 r .Amountpl <br /> al_ -7 Po`ymentDate 'a D „ <br /> r� 'Payment Type Invoice'#r ,Check#.', l FieceiVed By:� I, <br /> ' EHD 48-01-025. 1� SERVICE RE0096T FORM' <br /> REVI SE[b 6;5-02 <br /> r <br />