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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAI TT-I DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�DO 345-7 � <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> /19 . LOu/s �G / <br /> FACILITY NAME r•r ,/ � � „A 7-,5,7-0R a f�1 <br /> SITE <br /> //ADDRESS <br /> '11 K V L5 u/HS 1"Ae t le TF-(C./FZ pp-, / f�-t-C <br /> T/Y}'�O� Street Number Direcllon street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( 5't 0) 3793 - ,-7 7 --a(O— /v PA - 0 -3 - O - I) sA <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ✓o / <br /> tJ c xx= �/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME /1 �rF—1./e �G�/SULT/NC PHONE# - 7 Ezr, <br /> ltl <br /> HOME Or MAILING ADDRESS FAX P t) , ©/t 379 # <br /> CITY n „` STATE CA <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL HCALTI-t 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FED ws. 7 7 <br /> APPLICANT'S SIGNATURE: Q DATE / / <br /> PItOPFItTY/BtISINR.SS OWNER❑ OPERATOR/MANACFit ❑ TIIF.It AUTHORIZED ACFNTZ <br /> If APPLICANT is Nor the Bu.LINC PARTY.proof ofauthorization to sign is required Title <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 /> informalioh to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII 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: Nt TRATE 147AD(N6 -7-rVq1- <br /> COMMENTS: <br /> iI wisioN <br /> APPROVED BY: EMPLOYEE#: 1� v DATE: -N-0 <br /> ASSIGNED TO: EMPLOYEE#: ol DATE: I-( i -O) <br /> Date Service Complete (if already completed): SERVICE CODE: S 25 P 1 E: -L((p2 <br /> Fee Am.ount: 445 Amount Paid 1 Payment Date 3 <br /> Payment Type Invoice# Check# L -- Received By: <br /> HD 48-01-025 SERVICE REL <br /> Tr-VISrD r-5-D2 <br />