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SAN JOAQU*OUNTY ENVIRONMENTAL HEAL WEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gck:t�> �*A <br /> OWNER/ OPERATOR <br /> CHECK If BILLINGADDRESSE] <br /> FACILITY NAME C <br /> Q-S 1- V\ 4Z_ 1 VI <br /> SITE ADDRESS Z Z OC) e� <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#1 EXT. APN# LAND USE APPLICATION# <br /> (LIM H -� 2 - 163a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR — <br /> ^`�, CHECK If BILLING ADDRESS <br /> BUSINESS NAME 11l_ \w�� _ PjONE# / EXT. <br /> E ''i T v C�L t U C" J- L KQ <br /> HOME or MAILING ADDRESS FAx# <br /> Ua y612— <br /> CITY <br /> CITY Cy, STATE Qn ZIP C -2 -- <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 ENVIRONMENTALiIf'sALTit DFI'ARTME.NT hourly charges associated with this project or <br /> activity will be billed to nue ur my business as idcn(ificd un this 101111. <br /> I also ccrtily that I have prepared this application and that (lie work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,SlQAdQI' s, S"PATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ) - d <br /> �� �_�J�-- DATE: <br /> PROPERTY/BtISINFSS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I;� <br /> /f APNI.lCANT r'not tlr BILLING P 1 RTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO REL , SE 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 INVIRONMEN'fAL HEALTII DEPARTMIN"t'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: <br /> LAYMEN i <br /> COMMENTS: <br /> AUG 3 0 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: tJL I�� �J EMPLOYEE#: 03-;_,4 DATE: M <br /> ASSIGNED TO: / EMPLOYEE#: 36 70 DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: tq 06 I E: _363 <br /> Fee Amount:-f d 7R 0� Amount Paid ��9 Payment Date 3 I <br /> U <br /> Payment Type Invoice# Check# g Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORK <br /> REVISED 6-5-02 <br />