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bAN JOAQUIIN COUNTY &MVIKONMENT•AL nE•AL•I'M ULFAK•1•MLN•1 <br /> SERVICE REQUEST - -- <br /> Type of Business or Property FACILITY®i SERVICE REWEST t <br /> 5� '(v7ly�c <br /> OWNER/OPERATOR j2- 1z <br /> O g E t'—T l.,h CT-O(ZI O CNEcx N&wNc ADOREss{61 <br /> FACIUrY NAME LR"6?4D PXOPER-"ty <br /> SITE ADDRESS O 5 7 S• J Rcic_ -r-O r-J E R-o -?-15- <br /> I <br /> Street umber t Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5 AA1x.. <br /> Street Num Eer S~Na <br /> CITY STATE ZJP <br /> PRONE 41 En- APN f LAND USE APPLICATION# <br /> IZ011 +3I 1i3 lea- Z30- J-1 • - yZ _ / _ , S <br /> PHONE#2 EaT. BOS DISTRCT LOrAnONN CODE <br /> ( ) 0 1 619 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REOUESTOR A13-5c-L0 <br /> 1 CrEtic if BttuNG ADDRESS <br /> Err. <br /> BUSINESS NAME 1Ot1A <br /> I�VE OAK- G�6t:NVIR-oNM7-6 E�ITAt_ 7-6-j) '31o5 - o3'7i <br /> HOME or MAILING ADDRESS o^1-- STi2" <br /> . I '} <br /> 091 3L,,t ` o3} <br /> CITY L-01>1 STATE L A ZIP q 5 <br /> BILLING ACKNOWLEDGEMENT: L the undersigned properly or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARI'MI'N I hourly charges associated with thR project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAt'Jl rnn)I IN <br /> Cot m-ry Ordinance Codec,Standards,STATEand FEDERAL la s. <br /> �"'`t .A <br /> APPLICANT'S SIGNATURE: 46-IL �' i� y DIF: <br /> ppt <br /> PROPERTY/BusINFBS OWNER IOOPERATOR/MANAGER ❑ OTHER AirritoRIZED AGENT❑ <br /> /f APPLICANT is no!the BILLING PARTY.proojof aNrhorizadon to sign nls required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmernat/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALIH 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: IZEV k E IAJ 5*09-It C-E * S✓SS �F GorJTA'M wAT­i on) R£PoFZ•r <br /> CoM Ews: /.s/�v PAYMENT <br /> 7?c�tn7Q�iiir�Jr� RECEIVED <br /> M- F-Ebb!>O AUG 0 9 Z013 <br /> N JOAOUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: ?-6 7U <br /> C } {'•. 4 <br /> ASSIGNED TO: TR w EMPLOYEE#: Lf()q GATE: <br /> Date Service Completed (it ahvady completed): SERVICE CODE: 3 i S PIE: Zb D 3 <br /> Fee Amount: 2S�) Amount Paid Payment Date y 3 <br /> Payment Type +;' Invoice# Check# 104751 Received BY <br /> EHD 48-02-025 - SR FORM(Oo41en Rod) <br /> REVISED 11/17/2D03 <br />