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HtGSV <br /> SEP 112014 <br /> SAN J•OAQUIN COUNTY ENVIRONWNTAL HEALTH-DE P � <br /> SERVICE REQUF,,sT � ��������,.:I� HEALTH <br /> C: <br /> Type of Business or property FACILITY ID# s>:Fvlce REQUEST# <br /> OWNER I OPERATOR <br /> ACUTY Wm <br /> SIT ADOftE93 At, <br /> t vc0 <br /> Street Nu eer Dlra�tlo CL-Ct Nar Cit =Code• , <br /> HO?AE or MAILING ADDRESS (If Differont frorn Site Address) (00 t <br /> Street Numbe Sfr <br /> Crit STT ZIP <br /> 6 <br /> PHONE#1 Mn. TPN Yr <br /> ( AOT LAND USE APPLICATION#PHONE#2 LY LJt Exr. <br /> ( ) BOS DISTRICT LOCATION�CraDE <br /> CONTRACTOR/SERVICE REQUESTOR (eAE5 <br /> REQUESTOk <br /> � "�L•QJ ��� �� CHECK If <br /> BUSINESS("LAME PHONE#C -HOWIE Or MAI>,INo ADDRESS SIMFAX <br /> qt'*" <br /> city <br /> ZIP <br /> JL1 lIV ACKNO EDe:EIVIENT: (, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific ENVaaNNfsmrAr.ffE kL-rH DEpARTi ENT hourly charges associated tivith this project <br /> or activity will be billed tome or my business as ideaL.fled on this form. <br /> I also certify that I havc prepared this application and that the woo.to be performed will be done in accordance with all SAN.foAQUIN <br /> COUNTY Ordinance Codes,Standard,?,STATE and FEDEr2A; WS <br /> APPLICAN1"S SIGNATURE'-- L <br /> DATE: <br /> r <br /> PROPERTY/BU$INE$g pliN$RL OP.EkATOR/ Y ANAGER ❑ OT.UERAUTHORIzEnAGENT <br /> IfAPPLICAWT isnot the B/ T,yGP.4R 'prvofofattthorizatiptt to sigtl is required <br /> AUTHQP,IZAT1QLT0 RELEASE INFORMA":CO_N: when applicable,I,the owiier or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical d4ta and/or envirolut:ental/site assessment <br /> information to the SAN.IOAQUTN Cort y 11NVIROMENTAL HI,A TYDLr?AR.'t ,FENT as soon a5 it is available and at the sain i it is <br /> provided to me or my representative, Y <br /> TYPE OF SERVICE REQUESTED: Lrti t4.+ <br /> CornMsnrs: 4•+ <br /> COV <br /> SPAN� 0 <br /> ACCEPTED BY: ( EMp�9YEE#; <br /> DATE: G <br /> Ass1GNED TO: } `I <br /> �`��•��� EMPLOYEE 4: DATE: <br /> Date ServEc©C4Rt letaq (jfafre dy completed): SERVICE CODE: 1 G - <br /> t PIE: '.. <br /> Pee Amount: �7` <br /> j Amount Paid yj � Payment Fate <br /> Payment Type €w� lnVO a# ' <br /> Reeelved By: ' �i <br /> F-HO 48-02-025 <br /> R>VISED 11/17/2003 SR FORM(Golden Rod) <br />