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' SAN JOAQ�—N COUNTY ENVIRONMENTAL HEAP "H DEPARTMENT <br /> a SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# LSERVICE REQUEST# <br /> 5yQ-53 <br /> OWNER I OPERATOR�j`TW [ T CHECK If BILLING ADDRESS ElFACILITY NAME <br /> SITEADDRESS <br /> lj }� ('�'`j'�! <br /> 6 V Nu DireN3on Street Name Cit T- <br /> ZI.Code <br /> HOME or MAILING ADDRESS (If Different <br /> �from Site Addr <br /> •" ►y Street Number Street Name <br /> CITy ��� CA $TATE � ZIP <br /> 1414 <br /> PHONE#1 lY1 J� EXT, <br /> APN# LAND USE APPLICATION# <br /> ('70 ) 3 - 073 M 5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> i } <br /> CONTRACTOR l SERVICE RE' QUESTOR <br /> REQUESTOR.51 /)M r CHECK if BILLING ADDRESSO <br /> BUSINESS NAME WL PHONE# EXT. <br /> } <br /> ROME or MAILING AoDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property ar business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMI NTAt.14EALTii DEi'ARTMENT 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 Cortes,Slandarlfs,STATE and FEDERAL laws. +p <br /> APPLICAN'T'S SIGNATURE: DATE:. &S-9- 7A2- <br /> _O �3 <br /> PROPERTY/1311S1NERSOWNE.R❑ OPERATOR/h'IANACER ❑ OTHritAtJTtIORI7.EDAGENT ❑ <br /> If f1 PPl.M."ANT iN riot the B11.L1NG•PARTY,proof of authoriZation to sign is required Title <br /> AU'I'IIORIZA`TION TO RFLEASE, 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 /> informadott to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTiI DEPARTME-Ni' as soon as it is available an he same time it is <br /> provided to me or my representative. <br /> TYPE bF SERVICE REQUESTED: S 5RE <br /> COMMENTS: 9' �t�4'" 3 f/5/to <br /> g <br /> /fir <br /> Gto..�/tJ�+ r4 <br /> ,.Thi l`� �� " <br /> ,-, <br /> APPROVED BY: `,� EMPLOYEE#: DATE: t)j <br /> ASSIGNED TO: y EMPLOYEE#: t C' DATE: <br /> Date Service Completed I already complet d): SERVICE CODE: G P1 E: <br /> Fee Amount: Amount Paid 7t� Lob Payment Date 2 <br /> Payment Type Invoice# Check# T1 1-7 Received Ely: <br /> EHE 48-01-025 SERVICE REQUEST FORM <br /> RFVtSFD G-5-07" <br />