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In IiAM <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAIJlyd DEPARTMENT <br /> SERVICE REQUEST <br /> I <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS O <br /> FACIlrfY NAME u�L46M,6 —Z—OC <br /> SITE ADDRESS fAC <br /> Street Number diron � r N O�� � � <br /> HOME Or MAILING ZAI�'/�1y ADDRESS (If Different from Site Address) <br /> l v4.4a - Street Number -Street Name <br /> CITY STATE zip <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> { r I C&- # 0 -V3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION COOS <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQU ESTOR /� <br /> i �_L� P k r !�/i n fie,{ e 1 CHECPC It BILLING ADDRESS <br /> 7 f I1�171�f'L�[�aJrlJ PON 9 y EXT, <br /> BUSINESS NAME /P J IR ,fin ` ,i r -q22 <br />{ HOME OP MAILING A E'$^a +[1� � '/j � # Q-4 G <br /> CITY � ! 1 1`] STATE zip <br /> f BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, 7- <br /> acknowledge that all site and/or project specific ENVIRONMFNTALHEALTH DFPARTMENT hourly charges associated with this projector <br /> Ck- <br /> activity will be billed to me or my business as identified on this form. PAYMENT <br /> RECEIVED <br /> I also certify that I have prepared this application and that work t be performed will be done in accordance i all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA nd FCD L I Z 8 2OD <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BuSINESS OWNER[3 OPERATOR I MANAGER © OTHER AUTHORIZED AGENTR F7 ME <br /> Cl ws (J- <br /> IfAPPucAlvT is not theBILVAgPARrY.proof of authorization to sign is required. Titte <br /> AUTHORIZAT10ji 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 COUNTY ENVIRONMENTAL HEALTH 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 REQuvs-rED: ,�`. <br /> COMMENTS: 7-0 /C:t1�A Zr��VV! <br /> ro � •+r�r.�`� L1/z 11c _s�-sTr�t', �r•!T>� UST" �1T1'rAl• ?,>I-- 70 <br /> i Y - <br /> -<bA J e- t Pc.°A'rf- IMF. 7- FbOTM* ?gem 619e s <br /> ACCEPTED BY: EMPLOYEEM DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE' <br /> Date Service Completed (if alreadyaompleted): SERVICECOOE: �� PIE: . <br /> Fee Amount: �' Amount Paid I , "' Payment Date <br /> Payment Type G Invoice# Check# -7 Received By:' <br /> fr <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />