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SAN jOA'Q 'CWJI�d`- ',-E VRIONMI~Y AL EA ;TH""?A1,:TTYIi~:N i <br /> SERVICE REQUEST <br /> Type of Business or Property ` ! I� Fat:al.6T°s D-41 <br /> I .:ERViCERcQ�;E.aT# <br /> OWNER I OPERAT04 <br /> r 3 <br /> � ;5Ire., own er � � '{ �. � CHECK if BILLING ADDRESS <br /> � 0..i <br /> FACILITY NAME0{�� <br /> 6/\G <br /> t SITE ADDRESS t <br /> t"'�<wi Strait Numbor Dire4511 <br /> ction S4rwet Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Difl--r,r frorTLSIte[Address) 62-(:;, S' <br /> � ` 7 <br /> ©�ejt�. �l�Ct�i <br /> Sirae4 Pdumber Stroot Namo <br /> f A CITY r STAT[ zip <br /> 1 / <br /> PHONE#'I E.' TPN# LAND USE APPLICATION# <br /> s"7 <br /> CODE <br /> LOCA <br /> PONE#2 EXT. <br /> �t30S DISTRICT T70P2 <br /> 71 <br /> i•8[QUESTOR CHECK if 34LLING ADDRESS 7 <br /> ES NAME PHONE"; BUS� EXT. <br /> X <br /> u HOME or MAILING ADDRESS � � �t� "� FAx# <br /> OITYC-( l ;iTA7L /� (� 21P 05 6-0 <br /> Bri'LING ACK14 OWLEDGEKE N"T: 1, the undersigned property or business owner, operator gr authorized agent of same,, <br /> g R' acknowledge that all site and/or project specific ENvmoNmr-NTAL HEALTH DEPARTMENT Dourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this forin. <br /> I also certify that I have prepared this applicaPpnand that the work to be perfornicd will be done in accordance with all SAN JOAQUIN <br /> COUNTY°Or distance Codes,Standard!,STA ;rand FES ;RAL laws �g <br /> tf 7 t ? Afwr �..5$qNATURE1T. <br /> a> <br /> I'R TY/BUsrNGtiSOWItiERL� ®PEItATOR/MANacER AGIEN-TEI <br /> s If APPLICANT is not the 131LLINGPARTY Proof Ofauthorization 10 V i,,;ll iS rcquired Title <br /> ' ATP1-F®RT7.A'a0N TO R19,LEASE INEZIRATATION: When applicable,1,the owner or operator of tnc property located at the <br /> f.`, <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HE.ALTEi DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 5 t <br /> � 4 <br /> U <br /> COMMENTS: MAY - 9 2003 <br /> SAN JOAOUIN COJNTY <br /> PUBLIC I"ALTH SERVICES <br /> ENVIRONPWilTAt HEALTH DIVISION <br /> APPROVED BY: ,1" iYh'LOYEE'ie: 1Z��--L, <br /> DATE: Y--C, Cid <br /> s <br /> i. .asslGaA:Et?To: y'� . �J f `idPLovEE UA <br /> 'DATE: j C^i <br /> Cate Service Completed (if already coarp6etad): SERJ7CEC0DE: t P i E: Z yo <br /> 7� <br /> Paym <br /> Pee Amount: �j Amount Paid C3 Lr. ent Data G <br /> ' a Payment Type invoice f®-z o-7Check# j�� Received By. � <br /> l EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> r <br />