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1 il-IH FLUUR r'�ai.u= rJd <br />•`• • ••`w,r,•,EVjly vuLv t r r,1"� V11t .NXIZ YTAL J4EAL <br />>E'PARTM:IrNT <br />SERVICE REQUEST <br />Typo Of 8uslness or Property FACILITY ID # <br />SERVICE REQUEST # <br />I OWNER / OPERATOR <br />r DA �N� — Hl~CKifB+�uwoADs❑ <br />FACILtIY NAME' <br />SITE ADDRESS <br />/rWz z, Tv �) i�€ �S`TccKToilJ 95aa� <br />HOME Dr M ALINU ADDRESS (If Different from Site Address) $ Name <br />`n m LI Cad <br />CITY rat Number Stryat Name <br />STATE Zip <br />PHONE M EXT. _ <br />AAN #LAND USS APPLICAuoN # <br />PHONE #Z ExT. <br />( BOB DISMC7 I LOCATION 008E <br />C0NTRACTOR t SERVICE REQIJEST0k <br />REQUESTOR <br />CHECK If B'L'mo ADo�ass <br />SUSINeU NAME n III <br />S�' <br />PHONE# Ext. <br />HOME Or MAILWQ ADaRE;3$� OQ <br />FAX # <br />CITY ®® AG �ef <br />STA7E C7,,V <br />AILLING ACKNOW) � ivI iyT= __� zIP 9J.1?�D__ <br />acknowledge that all Site and/or project Specific ENVIRONMENTAL property <br />DEPARTMENT hourlyor business Owner, echarges associia d with this project rator Or authorized agent of or <br />activity will be billed to we or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUM <br />COUNTY Ordinance Codes, SAftnelards. STATE and FEDERAL IaWS, <br />APPLIC.ANT'S SIGNATURE: <br />-- DATE:r— <br />P;tOPERTY / Bt'ME 0%VNLR❑ <br />Or�Ri AIYACER ❑ ER AUTHORIZED AGENT J$I <br />If .4,PPLtCkW is not the BILLINGPARTy prvaf ga+rthorjZa1&n to sfgn is required ®/U I i Title 7-6 �- <br />ALtIHORIZATION T4 N: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authoriac the release of any and all results, geott~chnical data anJ/ar environmental site assessment <br />information to the SAN JOAQLrN COUNTY E,WIRONMENTAL HEALTH DEPARTmE*"C as Soon as it is available and at c <br />provided to me or my representative. �AYit is�,satz�,tim <br />TYPE OF SERVICE REQUESTED: ETv' v <br />OCT <br />ACCEPTED BY: /;l <br />ASSIGNED TO: � � �•�_ <br />Bate Service Completed (if already completed): <br />Fee Amount: Amount Paid <br />Payment Type Invoice # <br />EHD 4so2-C25 <br />REUSED t 1/17/2003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />EMPLOYEE#: C 2 � bA7E: <br />EMPLO'fEE #: PIIS_ ( DATE: <br />SERVICE CODE: I' P / E: 3 C <br />r Payment Date <br />Check # ! v v v <br />(9 �i Received By: Q <br />SR FORM (Golden Rad) <br />PV <br />