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SAN J0AA1Ir,C0IfN1% <br />slr:l?"( "': 1? ""NA 1� 4 2014 <br />IType of Business or Property FACILITY ID # SERVICE REQUEST <br />A k,E L- <br />rLc�-, A J ENVIRONMENTAL H ALTH <br />OWNER / OPERATOR DEPARTMENT"' <br />L Ph tj co L -L -C 011 (.A it oil I ING Ao)tif ss ❑ <br />- <br />FACILITY NAME <br />SITE ADDRESS <br />qOL to f L CA <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY � -mto l, <br />PHONE #I Fxr <br />PHONE #2 <br />ExT <br />Spool N4mo- ClIv 7.4r C <br />STATE, 1-7% ZIP <br />APN # LAND USC Aj,vt ICA TION 9 <br />C)"I S- I z 0 - <br />CONTRACTOR / S11?V1('11'1 <br />TOR <br />S W <br />—PN- I a r—AJ(Slf-)-EF-EZ <br />HOME or MAILING ADDRESS <br />-R &qo -S <br />Sortj.b dktitj%")o tz-ucS� <br />BOS DIS riii(, T I LOCATION COOS <br />cm CA it <br />PHONE # <br />FAX <br />CITY :S v VE,:"z - (G(. I ) -2! �� <br />C -1 <br />'t)V rj��j STATE ZIP <R, 13ac <br />BILLING ACKNOWLEDGEMENT: 1, (tic undersigned property or husiness Owner, operalor of 1111thol-i'led agent 4111'sumv. <br />acknowledge that all site and/or protect specific FNVIRONIVIFNIA1 III A( 111 DI:PARIMI N I hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this l'brin <br />I also certify that I have prepared this al)plicatiol, and thIllthle Zrk with be performed will be done in accordance Ith all SAN JOAQ1 IIN <br />COUNTY Ordinance ('odes, S1W7(1f9-dV, S] A I I . and FIA H; RA UVVS. <br />-) <br />vf,."s <br />A11111,WANT'S S1GNA'UURt;: IM I <br />PROPERTY / BUSINESS OWNERO 01�t:wvro AN ICER C1 <br />t(APPIKANTiS nOl Me :Blii, I prt►t►f of <br />n to sig -n is required Tijle <br />AUTHORIZATION TO RELEASE INFORNIA11ON: When applicable, 1, 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 ('0UN I ENVIRONMENJAI HEALA41 DEPAR IMI:Ni as soon as it is available and at the sarne time it is <br />provided to me or my representative. <br />TYPE OF SERVICE <br />COMMENTS: LV,0,;CA C- I -vio CON vw,,v- V-,,Ao4 Ste. Ir- 15— qv— U I I- <br />rl-&? L4,ce, %!:U N C% <br />ACCEPTED BY: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED <br />ASSIGNED TO: <br />To <br />EMPLOYEE <br />DATE: <br />rV <br />Completed Date <br />Date Service Completed (if already completed): <br />NICE CODE: <br />P/E: <br />Fee A <br />Amount: <br />MOU t <br />Amount.. Amount Paid <br />Payment Date <br />PaymentT <br />Payment Type Invoice # <br />Check # Received By: <br />EHD 48 02-025 SR FORM (Golden Rod) <br />REVISED 11/17i2003 <br />