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SAN JOAOA& CENVIRONMENTAL HEA0i DEA ARTMLNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY—16-#— SERVICE REQUEST# <br /> Fv,p,I ► r't Faci I1 � FAoao a- +Eo 5A0033g �-- <br /> OWNER/OPEGR�•ATOR / I� `(� I,' <br /> i <br /> sec)r7 C ✓e,l' / s f tSY�-o ��D� 1�'t 4 u((' W G f-I-/L 'n J r�Wne-� CHECK If BILLING ADDRESS❑ <br /> FACILITY MA�iIE l C 1 <br /> -1'a..c l M;yli -- M 0- Qt- (tea J <br /> SITE ADDRESS 4S I Q G` � R52Q <br /> l(Fl <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2V; Crooked ShLk Ci�cle� <br /> CITY <br /> Street Number Sr�� Street Name <br /> /' y„ Ali <br /> PHONE 01ExT. <br /> 10l APN# <br /> 7 <br /> LAND USE APPLICATION# P 230 - 1 1 4. <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> t�o� ) QS I -I2o1 P:�-I1•.wr W add' <br /> CONTRACTOR SERVICE< RCQU t STOR <br /> REQUESTO a-e— �°r'�to I <br /> C1 l-e-� CHECK if BILLING ADDRESS <br /> BLISIN NAME v PRONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> l(0 S Ct C-U-came-n C. ( ;?09 ) <br /> CITY .--:�*oC..0-0--e� STATE CA ZIP ZO 2 <br /> MILLING ACKNOWLEDGEMENT: I, the undersigned property or business owned-, operator, or authorized agent of sante, <br /> acknowledge ilial all site and/or project specific ENVIRONMENTAL I-IEALTli Dfil°AR'i'MGN'r hourly charges associated willi 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 Codas,Slantlat-(Is,ArATE and FE�/DDERAL laws. <br /> APPLICANT'S SIGNATURE: l.bJ DATc: <br /> PROPERTY/BusINESSOWNER❑ OPERATOR/MANAGF,Id ❑ OTHER AUTIIORIZ,ED AGeNT g <br /> If AI'I'LICANT is not the BILLING PARTY.proof of authorization to sign is required Title , <br /> AUTHORIZATION TO RELEASE 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL I-II.AL'I'll DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VSA P1 PI co S f 41 10-fn t^ PAYMENT <br /> COMMENTS: <br /> MAY 15 2003 <br /> SAN COUNTY <br /> w•mow I�G�UI ljL �d J PUBLICO HEOALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY: IILW EMPLOYEE#: Z 0 'L DATE: 0 <br /> ASSIGNED TO: EMPLOYEE#: DATE: ( 5 p <br /> Date Service COm eted (if already completed): SERVICE CODE: 3 ( PIE: `l 3o <br /> Fee Amount: '� 1 Amount Paid Payment Date <br /> Payment Type / Invoice# 00116 If Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />