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SAN .IOAQ V COUNTY ENVlRONM1'Wl'AL HEA' —ti DEPARTMENT <br /> SERVICE REQUEST <br /> ` Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S� oC 33 cl s 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Lu, <br /> FACILITY NAME <br /> SITE ADDRESS 11 6t_5 <br /> r �� <br /> Street Numher Direction '\ Street Name City Zip 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 APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( , <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> z4 <br /> HOME or MAILING ADDRESS FAx# <br /> 116 TLS. ( 09') <br /> CITY / STATE ZIP g SZ yG <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sane, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HGALTI I DI:PARTMFNT 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 OriNnancc Crudes,Slandarils,STATE'and FI'DL•ItA1-laws. <br /> APPLICANT'S SIGNATURE: r DATA,:: c <br /> PROPEIVI'V/ BUSINESS OWNER❑ OI'GRA"roit/MANAG.I•at ❑ 0,rm-itt AUTHORIZED AGENT❑ <br /> if APPLI(ANT is not the BILLING PARTY,proof of atilhorization to sign is required Title <br /> AU'1'1I0RIZATION TO RE1,EASE 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 environntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL I-IGAL'I'll DI:PAltTMENT as soon as it isPaxa the same time it is <br /> provided to me or my representative. NPS C\\181 <br /> TYPE OF SERVICE REQUESTED: t t ( 514 Jk t U d 'Zp�3 <br /> COMMENTS: <br /> /` �+.•�'� �ari � � � 7 ��Q.� SAN`O NQP SH S RH p�Vae <br /> 1�S10N <br /> APPROVED BY: EMPLOYEE#: -2��'� DATE: <br /> ASSIGNED TO: EMPLOYEE#: 5-3/ DATE: S Z3 -O <br /> Date Service Completed (if already completed): SERVICE CODE: ZZ PIE: 2b <br /> Fee Amount: 1-7 00 Amount Paid Payment Date <br /> -T- 13/03 <br /> Payment Type CA-5 t t- Invoice# Check# Received By:-Z.,(- <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />