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SAN JOAQL BOUNTY ENVIRON' FAL HEA' wDEPARTMENT <br /> SERVICL—R--QUEST <br /> Type of Business or Property FACILITY ID# <br /> ,�j�NcH SERVICE REDDEST# <br /> OWNER/OPERATOR/�`/t <br /> FacILmNAME CHECK if BILLING ADDRESS <br /> v � <br /> SITE ADDRESS (� <br /> Street Number Direction Street Name ' <br /> HOME OfMAILINGADDRESS (If Different from Site Address) a n cone <br /> 3E / Street Number <br /> CI ' ,y/ �1, Street Name <br /> fR�///U/V STATE zip <br /> PHONE#f EXT. APN# LAND USE APPLICATION# <br /> 1-171—a3'91-1 c5"Iv ) pA--C'? <br /> PHONE#2 Exr. <br /> BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A.AO IL/Mrn�� // � - / <br /> �'I !7 !'S 'tG CHECK((BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# En. <br /> O <br /> I IR- <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY $TIT IIP 97J /J <br /> e iu J <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 ENVIRONMENTAL HEALTH 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. �y, <br /> APPLICANT'S SIGNATURE: /221� �--r��y�<<r� DATE: /b J n <br /> PROPERTY/BUSINESS OWNERtp— OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLICANT"/r fs Hot the BILL/NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO REI,EASE 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 I4EALTH DEPARTMENT•S s on a5 it is available and at the same time it is <br /> provided to me or my representative. s -� <br /> TYPE OF SERVICE REQUESTED: N l� CI L/LI n <br /> COMMENTS: <br /> irr:ten "_ \NI �^SSC.G- (seri <br /> N <br /> adz' <br /> APPROVED BY: T L n><o/li�nB-1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: O/ q DATE: /Q <br /> Date Service Completed (if already completed): SERVICE CODE: rJ`ZS P 1 E:�(P �T t <br /> Fee Amount: 00 Amount PaidU Payment DateK , <br /> D <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 4""25 'aet/2 — SEP`.'IGE REGO <br /> REVISED 6-5-02 <br /> QMw' <br />