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SAN JOAQUI0%..,3UNTY ENVIRONMENTAL#I�ALT ,aPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 'FACILITY ID# SERVICE REQUEST# <br /> S2C) o 3 Sv $— <br /> OWNER/OPERATOR <br /> �� CHECK.if.BILWNG{�OpRESS <br /> FACILITY NAME <br /> SITE <br /> 'jADDRESS <br /> lfes . Ld�l �lS <br /> 0 Street Number Direction l Sheel Name L. cityZi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE AP 1 THIN# <br /> ( 1 3�� —��i�2 063- zs- o z mays <br /> PHONE#Z Eat. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR4t ,A <br /> /"c U� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> b; / Icr`, z �� Lj zit 3W-roq,/3 T <br /> HOME or MAILING ADDRESS D Frac# J <br /> Sp. gc Zl8 (2� ) 4'O�2 / <br /> CITY C-A) 7->1 STATE 64 ZIP cS-Z-i/ <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 ENviRONMENTALHEALTH 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> } r Z Z -� <br /> PROPERTY/BUSINESS OWNER❑ 0ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ca <br /> JjAPPUGNT is not the (LUNG PAIt7T proof ajauthorization to sign is requires/ 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 environmentaVsite 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. cc^^� � _ �1 <br /> TYPE OF SERVICE REQUESTED: ��,F!-1EE .3'L-C�-' RU r-f F= COA7T [�-�YOA--% P <br /> couuENrs: ECEI VED <br /> JUN 2 <br /> 2 2004 <br /> SAN JOAOUIN COUNTY <br /> ENVIRON HEALTME: "2-G" <br /> ENTgI <br /> ACCEPTED BY: ©�t.i�t A EMPLOYERSERVICE <br /> I` <br /> ASSIGNED TO: �,E4;I r,J A, EMPLOYElp <br /> Date Service Completed (if already completed): 3/S'Fee Amount p J Amount Paid iq' — yment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED il1i7/2n03 - - <br />