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SAN JOAQUiN COUNTY ENVIRONMENTAL IIEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 94oar 5+o--e ��•01251c.P3 S0,Oog2012, <br /> OWNER/OPERATOR <br /> t� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME i(1 �nP,r <br /> t <br /> SITE ADDRESS i � E I ' s•��(�P} �a N(� q j3 rj <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#`I ExT• APN# LAND USE APPLICATION# <br /> (51o ) SJR - Lt34 <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> (510 ) a�U Ll40 1 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ! <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ) PHONE# EzT. <br /> ti &Ve ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or protect specific ENVIRONMENTAL FII:ALTH Di:PARTT4ENT 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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDER.,1L laws. <br /> APPLICANT'S SIGNATURE: (l DATE:�Q j,?Ll J av <br /> PROPERTY//BUsINF:ss 0R,NEIttC1 OPERATOR/MANAGER ❑ OTIII' At'Tnojurttn AGENT❑ <br /> II'APPLICdA'T is not the BILLING PARTY,proof of authorization 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 authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COLJNI-1' ENVIRONMENTAL HI:ALI-1-1 DIiPAILTNIENT as soon as it is available and at the same time it is <br /> provided to nae or nay representative. PA <br /> AI <br /> TYPE OF SERVICE REQUESTED: �od Cot'1SS�t, RE ,v <br /> COMMENTS: ry „ � �� t_ 4�� <br /> l.1/llN V� ?020 <br /> 1V JOA QU <br /> H�q T ROIVMtcoov y <br /> H DEPART41SNT <br /> ACCEPTED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: — EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: 1 1„ OZ <br /> Fee Amount: � i(7 Z_ Amount Pa f�� D Payment Date � VJ <br /> Payment TypeV� _ Invoice# Check# rj X01�O Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P20c)4gz-7(0 <br />