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SAN JOACOUNTY ENVIRONMENTAL HEAW DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 60"r X00od ®Io7 <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> L G.J <br /> 6,Z- 3(7 P ' � CS � \L S2�/Ff/i� <br /> Street Number Direction �L ' \ 'Street Narhe`' �� Cit �h � ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. PN# = LAND USE APPLICATION# —, <br /> (Zqj) `17 (S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (ZrAcr) `l?Br - 6.3-17- <br /> CONTRACTOR <br /> 2CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �{ � <br /> 1✓�\�� ^� l �/6 1, O/ �p Ov` ��" rls1<BILLINGADDRESS� <br /> BUSINESS NAME (� PHONE#` �\ EXT. <br /> P yim8' 1 l —10 (J' <br /> HOME or MAILING ADDRESSt (AX# ) '�✓q-7& <br /> CITY STATE ZIP 'll. <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that t have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COON"I'Y Orrliiitinee Codes,Standards,S'I'A'1't-and Ft-DeI -laws. <br /> APPLICANT'S SIGNATURE: DATE: (//"_ <br /> � `f b 3 <br /> PI(DPI':It'rY/BUSINESS OWN Fit❑ OPERA"1'OR/MANAGER ❑ OTt11iRAUTIIOItIZEDAGENT X � <br /> e—7-0 <br /> IJfI PPLICANT is not the BILLING PARTY,proof of authorization to sign is regltired Tide <br /> AUTIIORIZATION TO RF..I,EASE 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 COON"rY ENVIRONMLN"rAl-I-IEAL'1'li 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: o CA, `� ` [ `Lk•r <br /> COMMENTS: l 1 1 1 <br /> (..J e- 1,4 e—t_':5't �"o Ito -A \ fie,L`�G�v.: `� 1 L e e.I� P Y S . �^1— 1.. <br /> e-x:, s <br /> a" e-t-"X eb/ , SAN JOAQUIN COUNTY <br /> APPROVED BY: EMPLOYEE MIRONMEN Ab TH IS <br /> ASSIGNED TO: EMPLOYEE M DATE: (J <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date ? <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> RFVISED 6-5-02 <br />