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SAN JOAQtWi COUNTY ENVP"ItONNIENTAL HEAL'T'H MPARTMWNT ' <br /> _ , ERVICE {EQUEST <br /> Type of Business 3r Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> V /� <br /> J ^J/jl /-} CHECK If BILLING ADDRESS <br /> FACIL:TY NAME f / j / w �� <br /> rpm K <br /> SITE ADDRESS] <br /> 2�Ov Street Number pirection <br /> Hoor AILING ADDRESS (It Different from Site Address) <br /> V <br /> TLL/ Street Number Street Name <br /> CITY !J � STATE ZIP <br /> PRONE#1 Ext. I AF'N LAND USE APPLICATIONpl- <br /> � <br /> PwoNE#1 Exp BOS DISTRICT 'I~LOCATION CODE <br /> CONTRACTOR / SERVICE ItEQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �] � PHONE# Ex;� <br /> HOME or MAILING AwRESS FAX# <br /> ./?0 1.0 3 � 9 <br /> CITY / }��� / /1 STATE ZIP <br /> 131I.LINf. AC'ti(NO�VllfEDGIENiENT;L1,,jthe andorsigne.d property- or business owner, operator or authorized�agent of same, <br /> ackriov ledge ilia', all site and/or project specific FNVIR0N%ILNTAL IIEALTH DLPARTIVfLN7-hourly charges associated with this project or <br /> �ictivit•; %vill be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this ap lication and that the work to be perforined %vill be done in accordance with al! SAN JOAQUIN <br /> COUN'T'Y Orcllnance(odes,Slarrdcn- , 7'E and FEDE aws. Z40'1q� ., 3 <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/13usiNF.ss O'•vNER❑ Ii.RAT R/MANAGER 13OTHERAt;THtn(IZET)Ac;t=\r <br /> l�APPLIC,INT is not lire BLI.NG PARTY,proof of authorization to sign is reriuircr Title <br /> AIJTHORIZA.TION TO REI,EASE INI'ORMATION: 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 environmental;site assessment <br /> information to the SAN JOAQCITN COUNTY ENVIR0NMFNTAI,HEAI,TH Du.VARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERVICE REDUESTED: ti (f f .-- , <br /> COMMENTS: I FIECEIVEP <br /> q n^� <br /> 21AUG <br /> r <br /> SANd©AQUIN�•�rJ;u; <br /> Hf ACENTAL <br /> TH DEPA MF'. <br /> ACCEPTED BY: EMPLOYEE#: ` DP,iE: 2, <br /> ASSIGNED TO: EMPLOYEE#: DATE: 000 !/✓ <br /> late Service Completed (if already competed): SERVICE CODE: "� <br /> Fee Amount: 2 �� Amount Paid l{ Payment Date <br /> j <br /> Payment Type Invoice# Check# 1�1 Received By: <br /> rHD 48-02-025 SR FORM(Golden Rodl <br /> r _-VISED 11157/20)3 <br />