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-)AN J0AVUIdN L.UUIN IV LNVIRONMLN 1 AL nLALl H ULPARI MLN i <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � <br /> � �A <br /> OWNER/OPERATOR <br /> QPt 1>1>AC-V-- GHec►c If BILLING ADDRESS El <br /> FACILrrY NAME PA t]17 ftc-y- <br /> SITEADOREss 2501 � . VLQEy AYE . E�CAt�vr.1R�3� v <br /> Street Number Dlrectlon treat Name C' ZID Code <br /> HOME or MAILING ADDRESS IN Different from Site Address) Z <br /> S 11 "1G F't R-b . <br /> Street Number Street Name <br /> CITY t S CA SON.' STATE C.A ZIP <br /> P140ME#1 EXT. APN LAND USE APPLICATION# <br /> (zoi) 8�33s- 2-0(a S' 2sts- 04() - ©& Pty - It00O-g <br /> PHONE#2 Ex-r. BOS DISTRICT q� LOCATION COVE <br /> t 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE©UESTQR a..$t3`� <br /> ry7 V—&C C-o CHECK if BiLuNG ADDRESS❑ <br /> BUSINEss NAMEt.tN vAK GAO r r.jv 1 �iA t�N riR t PHONE# EXT. <br /> zOq 3pq - 031 S <br /> HOME or MAILING ADDRESS FAX# <br /> 4o-4 w O It 'T- (2,)-1) 3O`t - 03-4 <br /> CITY 1_0 C) t STATE GR zip CI S-X-f-O <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HLALTH DI-Yearly FN-r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all Sari JOrA(UIN <br /> COUNTY Ordinance Codas,.Standards,STTE,�and FUDERXL laws. <br /> APPLICANT'S SIGNATURE: �! ' 7 / -t <br /> DA-r>•;; <br /> PROPERTV/BUSINESS OWNER❑ OPERATOR i MANAGER ❑ OT'rtr:tt At THORIZED AGENT® Co PJ S Vt-TA+'JT' <br /> ]f APPLI(ANT is not the BILLING P.41?"',proof of authorizaliorr to sign is 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 avthorizx the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAT rtt DEPAR-FMFN'r 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: JrXC%f(CVO ECEIUEF) <br /> COMMENTS: JUL - 7 201 <br /> ? I SAENV1RCNMENTA1- <br /> hiEAL-TH t7LPARTVENT <br /> i , <br /> ACCEPTED --s EMPLOYEE DATE: M! . <br /> ASSIGNED TO: y.� --�" EMPLOYEE#: �iC DATE: <br /> Date Service Completed (if already completed): rr7ERVICE CODE: P 1 E: ! <br /> Fee Amount: '7 % Amount Paid ?.Q tv Payment Date -., <br /> Payment Type Invoice# Chuck# C-T2 Received By: <br /> EHD 48-02-025 SR FORMA(Golden Rod) <br /> REVISED 11/17/2003 <br />